VISITING YOUR DOCTOR VIA EMAIL

"In a move to improve efficiency and control costs, health plans and medical groups around the country are now beginning to pay doctors to reply by e-mail, just as they pay for office visits. While some computer-literate doctors have been using e-mail to communicate informally with patients for years, most have never been paid for that service.

Brian Settlemoir, 39, an accountant in Folsom, Calif., recently sent an e-mail message to his doctor at the Creekside Medical Group to ask if it was time to reduce the dosage of a medicine after his cholesterol level dropped. The prompt answer was "not yet." "I'm sitting at work," Mr. Settlemoir said. "I've got e-mail open anyway. It's much easier than calling and getting voice-mail prompts and sitting on hold. It's very valuable to me."

Blue Shield of California pays his doctor $25 for each online exchange, the same as it pays for an office visit. Some insurers pay a bit less for e-mailing, and patients in some health plans are charged a $5 or $10 co-payment that is billed to their credit card and relayed to the doctor.

For doctors, the convenience of online exchanges can be considerable. They say they can offer advice about postsurgical care, diet, changing a medication and other topics that can be handled safely and promptly without an office visit or a frustrating round of telephone tag. And surveys have shown that e-mail, by reducing the number of daily office visits, gives physicians more time to spend with patients who need to be seen face to face.

For patients, e-mail allows them to send their medical questions from home in the evening, without missing work and spending time in a doctor's waiting room. In fact, many say exchanges in the more relaxed, conversational realm of e-mail make them feel closer to their doctors.

The patients can also use the e-mail connections, which they reach through secure Web sites, to get X-ray and test results and request prescription renewals. Doctors are not paid for these services, except in time saved in the office.

This shift toward online doctor-patient communication is important for another reason. Physicians and health care technology specialists say they believe that it could help spur the changeover to electronic health care information systems, which government officials and industry leaders say is needed to reduce medical errors and promote better care. Doctors at the clinics of the University of California, Davis, grew accustomed to using e-mail for clinical purposes before the clinics introduced electronic medical records, said Dr. Eric Liederman, medical director of clinical information systems at Davis. The messaging "gave them some comfort and facility with using the computer," he said.

Early research at clinics at the university found that using e-mail improved the productivity of physicians, decreased overhead costs and improved access to doctors for patients, including those who still telephoned. "There was a huge reduction in the number of calls," said Dr. Liederman, who is a big fan of e-mail exchanges.

Doctors and insurers say online consultations can be especially useful for patients who have chronic conditions like diabetes, asthma and heart problems. They have been frequent users and being in touch can help them to comply with regimens to cope with their diseases. "Patients love this stuff; I love this stuff; the staff loves this stuff," said Dr. Barbara Walters, a senior medical director at Dartmouth-Hitchcock Medical Center in New Hampshire......

Kaiser Permanente, the nation's largest nonprofit managed care company, has tested patient-physician messaging in the Pacific Northwest and is starting the program this year in Hawaii and Colorado as part of Kaiser's $3 billion information technology program. Kaiser's salaried doctors get credits for messaging, adding to their pay......

A bill introduced in the House on Feb. 11 by Charles A. Gonzalez, a Democrat from Texas, and John M. McHugh, a Republican from New York, for the first time included a provision to authorize Medicare to make "bonus payments" to doctors for e-mail consultations."

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