The Sacramento Bee reported that, since COVID, providers are dealing with a 50% increase in patient messages which yields an extra 2-4 hours spent NIGHTLY to clear their inbox.
To stem the flow of messages, some health systems have begun to charge patients for qualifying messages.
In this episode, we looked at the consequences of this decision and the implementation, by some health systems, of a chatbot to ease their provider’s administration burden.
Click to expand and read this episode's transcript.
Erik Sunset: [00:00:00] This is the DocBuddy journal. I’m your host, Erik Sunset. Thanks for spending a little bit of your podcast consumption budget with us. We’re recording this episode today, Thursday, September 14th, 2023. A little bit of housekeeping, then we’ll jump right into it. If you were at the Casa annual conference and that’s the California ambulatory surgery associations annual conference in beautiful Monterey, California, be sure a visit to DocBuddy at booth. Number 32 is on your dance card. We’d love to give you an in-person look at our oppnet solution, which makes instant operative reports approved from the point of care with images or reality for your facility. Again, DocBuddy booth, number 32 at Casa. We’ll be on the road for the next few weeks as well. Visiting the New York. Ambulatory surgery, associations, annual conference. We’ll be at the Minnesota ambulatory surgery center associations [00:01:00] annual conference, as well as Becker’s ASC. Florida bone society and the Washington. Ambulatory surgery center association. All these acronyms are a mouthful. Thanks for bearing with me there. All that to say, there’s plenty of opportunities from coast to coast to see DocBuddy op note and the rest of our solutions in person. And we hope. To see you there. So for today. We’re going to be looking at a story that the Sacramento bee published this last week titled as more patients emailed doctors for consultations. Health systems start charging fees. We want to take a look at the value chain. We want to look at provider time spent on this process. We want to look at the possibility. Of something like chat, GPT, helping physicians handle this mountain of emails that they’re receiving day after day, week after week, month after month. Obviously there’s a burnout concern built into this equation. In that burnout concern starts with [00:02:00] some data that we’re already aware of because also cited in the article. From CT Lin, chief medical information officer at the university of Colorado health. Shout out, you see health Denver. We’re obviously headquartered in Denver, even though I’m recording this episode in coral Gables, Florida. But CT, Lindsey. Chairs that their physicians are doing between two and four hours of pajama time work. Which is after hours each night, we’ve already talked about pajama time, charting, pajama time administrative tasks. And the fact that the physicians at university of Colorado health are spending between two and four hours each night, replying to emails certainly fits into that statistic. And it’s not really a good one. And the reason that some health systems are starting to charge fees for their physicians after hours, time, replying to messages. Julie spurred by the sharp rise in email messaging during the COVID pandemic at equip of plus [00:03:00] 50%. So you’re doing 150% of the messaging. Post COVID than what you were doing prior to the start of the global pandemic. And a growing number of health systems around the country have started charging patients. When either physicians or other clinicians are sending replies to patient messages. So the health systems that have adopted billing for some easy visits and we’ll look at which ones qualify in just a minute. For some of the visits include a number of the nation’s premier medical institutions, like the Cleveland clinic. Like the Mayo clinic, like San Francisco based U C S F health. Vanderbilt health. Shout out Nashville. St. Louis based BJC healthcare and Chicago based Northwestern medicine, and even the us department of veteran affairs, the VA are now charging. For certain patient messages to be sent to and replied by physicians. As one data points, and this is obviously state and [00:04:00] insurance dependent, but an emailed consultation for one patient in the Sacramento bee article, it cost her $13 versus her standard copay of 25. And we’re already raising questions about the value chain here. It’s obviously not sustainable to have physicians working for free for two to four hours each nights. But what does the fear uncertainty. And doubt of maybe being charged for an email message do for patients because it’s not immediately clear as a patient that this message is one that’s going to cost you. What does that mean for their health outcomes? If you have a patient waffling on, you know, do I send this message or is it going to cost me 13 bucks or more? Just to get a reply to my email. Is that worth it? And we’re especially looking at patients here who can’t necessarily afford to come out of pocket for just sending an email.
To date though. It doesn’t seem to carry too negative of a consequence because UCS F and that’s the university of [00:05:00] California San Francisco implemented charges for appropriate messages and saw only a 2% dip in message volume. Big caveat here though. My dear listener. UCSFs patients are being billed for only two to 3%. Scent of eligible eVisits. And this is at least partly because it takes clinicians extra time and effort to figure out whether email encounter qualifies for billing.
Let’s dissect that just a little bit. Your physician, your physician, because you want to treat patients. You want to lead people to the best possible health outcome that they can achieve. So you’re applying to messages, replying to emails, to your patient portal, through your other secure messaging app, whatever that may be. Great check that box. But now I got to figure out, is this a message that qualifies for me to bill it? We’re not. So you’re, you’re adding on to that pajama time. Charting [00:06:00] already. Pajama time. Documentation pajama time messaging. You get the gist of what I’m saying here. I needing the classified messages. To be built or not. So let’s look at what those factors are and messages that qualifies for billing. Is one where a doctor or other clinician response to a patient message that takes five minutes or more of the providers time over a seven day period and requires medical expertise. And you’re going to need to fit this encounter. It’s one of three billing codes for Eve as it’s that CMS. Gave us in 2020. So not totally unreasonable there. You’re looking at a binary factor of time. Yes or no. It took me more than five minutes over the course of a week. That it required my medical expertise. Maybe a little bit more of a gray area there. And then I got to fit this into one of three billing codes. To review the patient’s encounter, reviewed the appropriate labs, the medication, whatever it may be. And now I needed to figure this out too and let my billing team now. Not [00:07:00] great. There’s another factor here that eVisits that are eligible for billing include those relating to changes in medication, new symptoms. Changes or checkups related to a long-term condition and requests to complete. Medical forms now, I think you’re seeing the balance shift, the responsibility shift rather a little bit towards the patient. If you’ve got a new symptom. If you’ve got a chronic condition and a new symptom pops up. Is this really something that you want to send an email about or should you be going into the office? So I think there’s a little bit of ownership on the patient side that needs to be addressed as well. And the article is quick to call out that there’s no charge for messages about appointment scheduling, prescription refills, or some other routine matter that does require medical expertise and hopefully your software, whether it’s your patient portal slash EHR. Or however you’re handling patient messages. Hopefully you’re triaging those to the right place that a physician isn’t dealing [00:08:00] with, the questions around appointment scheduling or some other routine matter. Maybe their bill. So ownership on that side too, to make sure that messages end up in the right place. And you’re not putting clutter into a physician’s inbox.
Switching over to Erik Boosie, CMIO at the Cleveland clinic and that’s chief medical information officer. If you’re not familiar with the acronym. Mr. Boosie says the patients have not complained about the new billing policy and that they become a little smarter and more succinct in their messages rather than sending multiple messages per week. Here’s a spot where you know, that value chain and incentives comes back into play. That’s probably a good thing. I’m sure. Every medical practice, every facility in the country has a list of frequent flyers sending in. Series of emails over the course of a week or a course of a month, or the course of their treatment, whatever that may be. Where you’re going. I got to be kidding me. [00:09:00] My. What are you doing? Sending this type of messaging? You know, the answer or this is, you know, level one stuff, level one, reading comprehension type stuff. So I get that. That’s probably a good. Good thing that you are. Giving that type of a patient with that type of message. A second thought about sending it in a. There’ll be build obviously.
Good. So then moving on, ADJ home grin. Who’s the assistant professor of health informatics at UC S F. Shared that while patients with minor acute conditions may not mind paying for an email visit rather than coming into the office. The new billing policies could dissuade patients with serious chronic conditions from messaging, their doctors, quote. We don’t know who is negatively affected. He said, Are we discouraging high value messages that produce a lot of health gains. That is a serious concern. And quote.
That raises a little bit of a question for me. [00:10:00] And I’m a layman, obviously not a, not a physician myself. Well, what kind of emailed question an emailed response would produce a significant health gain? Now we’re in the world of value based care. We’ve always been in the world where physicians want the best possible outcomes for their patients. What exactly are we leaving in this perilous situation where an emailed response is going to produce a significant health game?
If that’s reality, if such a thing exists, this is raising a big red flag for me. Then assuming that first point is true, that an email response can provide a significant health gain. What are we doing with second and third order consequences? We’re an outcome is dependent on an email, but a patient is unsure if they’re going to be charged for it or not, or knows they will be in doesn’t end up sending in the question.
It doesn’t totally add up for me. And to be perfectly clear, I’m not suggesting physicians should not be reimbursed for [00:11:00] the time and expertise. I think they absolutely should. However, if there really are outcomes dependent on patients being able to communicate freely and that’s literally freely with their physician, then your value chains out of alignment. It just is. So in doing so though health system exacts are hoping that this pay to email arrangement will prod patients to think a little more carefully about whether an in-person visit might be more appropriate. Than a lengthy message. And I think, again, that’s a fairly reasonable hurdle to clear. Especially if you’re that provider receiving just an inordinate amount of clutter in your inbox. And by clutter, what I mean is low thought, low value messages and questions for patients. That if they had just read their printed instructions or even what’s available on a patient portal, if you don’t print instructions anymore. There’ll be no reason for the message. However, the article shows that if you charge for these [00:12:00] messages, you’re still receiving 98% of the pre-charge volume. So pre implementation of a charge per message policy. You’re still receiving almost a hundred percent of the volume. And that may change, obviously that may change as more automation or physicians become more savvy or more willing to charge for email replies. You might see that number go from 98% down to something like 85 or 90. That’s not a huge decrease though. I mean, we’re still talking about between two and four hours of effort for a physician to clear their inbox each night. So, what can you do? Well, university of Colorado health UC health has as experimenting with an alternative way of easing the time burden of ER, visits on physicians. And I want to stop here for just a second too. There’s a big difference between a question that. Requires medical expertise. That’s a followup type question. There’s a big difference between that and [00:13:00] Hey, I’m running a fever and my throat hurts and I started to cough and I’m not sleeping. That’s a new issue. That’s essentially a new type of encounter, not a follow-up question. So. Patient. What do you think you should do? Maybe set an appointment to see the physician, if it’s that big of a concern or. Go to CVS and get some cold medicine and tough it out and call the physician if you really do feel sick. So I think there’s, again, responsibility on both sides here to be able to handle the volume. As a provider. Volume of messages and there’s responsibility on the patient side, too. That, not everything warrants. Give me an antibiotic and I’ll be better. Well, What if it’s a viral infection and you got no business taking an antibiotic, it’s not going to do anything for you. And in fact, there’s a pretty strong argument to be made. That’s worse for the macro environment to just be taking antibiotics. Cause you want a pill. Anyway, a little bit of a soap box there. But when you see health is doing, is that they’re they’re an epic shop. As many health systems across the country [00:14:00] are. They are going to be using an artificial intelligence chat bot to draft email replies to patient messages. The chat bots draft message will then be edited by the provider. Red flag waving the red flag here. As I said before, I seriously doubt that any serious time-savings are going to be yielded here, except for the most basic mundane sort of a response. I do concede that this chat bot will save the time, needed to type a message. But. But the patient’s history and encounter notes are still gonna need to be reviewed by a provider. The chat bot reply will still need to be reviewed and edited. And hopefully its reply is really accurate. And that process doesn’t take very much time. I would not want to be the Guinea pig for this as a physician. That’s already burned out. That’s already spending too much time on administrative tasks. [00:15:00] You know, we’ve talked about the laws surrounding consumer protection with AI previously. A lot of that still being drawn up there really aren’t any laws or certainly no federal law that applies to patient protections with the use of AI in their treatments. The can you imagine? The crap storm that will ensue. If an AI chat bot reply. Is sent to a patient and it causes harm. Think about it. These are messages. Messages need to be reviewed very carefully and good physicians and good health systems are going to say, Hey, we’ve got a tool for you here. It’s a chat bot. It’s going to help your process, but you still need to review it. You’re still gonna need to look at the patient’s chart for context. You’re still gonna need to be sure. That, what this thing drafted for you is what you want to say to the patient. Because we can’t have this tool causing harm. Right.
So this eventually I think we’ll evolve into probably pretty elegant solution, but for [00:16:00] now the state of play in the state of technology in the state of that regulation, you’re going to be adding friction to this process by requiring more physician oversight over this chat bot, potentially more time than it would take just to do the process manually. So it is a very typical healthcare fix to just kind of move around the friction move around in the pain like oh you don’t have to type the email anymore the chatbots can take for you but you’re going to need to review it you’re gonna need to edit it you’re going to need to be sure that we’re cya cover our tails here from our compliance side of the house from our legal side of the house Cause we can’t just have the chat bot interacting with patients on your behalf because it’s not a doctor And as you’ll recall from prior episodes about things like Chad gpt These LLM. Lms these large language models they don’t actually know anything They’re a word predictor They’re a sentence predictor they’re a paragraph predictor and they look. look pretty good on the surface But i’ve yet to see an output out of chad gpt that was 100% [00:17:00] accurate You’re not getting the medical experience the medical expertise the medical decision-making that a physician brings to the table so the amount of oversight needed for this type of chat bot solution that’s really built to streamline a process I think you’re giving that up and efficiency for the review and the editing of that draft And i think there’s even one other important point to make here since Marty’s standing up so tall on my soapbox that because these softwares like ai chat bots llms chat, gpt you know, pick your poison there because they don’t actually know anything they can only know the things that the model is fed right so right now we’re talking about a message from a patient about either an existing or a new condition Which may or may not be better served with actual office visit but you’re you’re you’re relying on the model To have perfect data going into it to have a perfect [00:18:00] response What percent of medical records have an error It’s not zero It’s not 0%.
So basically what I’m trying to say is that unless you can guarantee all the inputs are perfect. You’re going to guarantee that somebody has to edit and ensure that the response is appropriate. And accurate.
All at all. I think we’re on the right track though. You know how seriously we viewed the epidemic of physician burnout. You know how seriously DocBuddy takes physician workflows and we do everything we can to ameliorate these workflows, to ensure physicians are not chained to their desk after hours, that they have more time for life. And if you’d like to learn more about how we do that, I’d encourage you to visit DocBuddy.com. Check out our solutions menu. You can see all of our different products that serve the across the variety of places of service and the physician. Mid-level and even staff may have from the clinic to on-call at the hospital [00:19:00] to inpatient, to the ambulatory surgery center. Again, that’s doc, buddy.com. Can fill out the contact form. Love to get in touch with you. Get you a customized demo of one of our products, as well as the value assessment and where we can save you time and money. And with that, we’ll sign off for this week’s doc, but a journal. Thank you again for listening on behalf of the entire DocBuddy team. I’m your host, Erik Sunset. We’ll talk to you again soon.