Considerable unreimbursed medical care is delivered through electronic patient portals: A retrospective review

To the Editor: The Health Information Technology for Economic and Clinical Health Act in 2009 required all medical practices to transition to electronic medical records with integrated patient communication portals.¹ Portals can be used for communication of test results, appointment changes, or patient questions about new or existing medical complaints.

We conducted a retrospective review to assess patient-initiated messages on the online portal used in the dermatology clinic at University of Texas Southwestern Medical Center called “MyChart.” We requested records for all face-to-face clinic encounters and provider contact hours from January 1, 2010, to December 31, 2018, in general dermatology, and patient-initiated MyChart messages were collected for the same period. Clinic encounters were calculated from the number of patients seen by each provider per year. Provider contact hours were calculated as the sum of the hours of booked appointments per year.

Using a population of 30,770, the number of patients seen in general dermatology annually, to obtain a 95% confidence level, confidence interval of ±5%, and SD of 0.5, we calculated a sample size of 384, rounded to 400, using the Cochran formula to determine the number of messages needed to review.² These 400 MyChart messages were randomly selected from all messages from 2010 to 2018 using a random numbers table to generate a list of stochastically selected messages to examine.

Data were then classified by message category: medical advice requests, medication refill requests, appointment changes, and medical history questionnaires. The message type was verified, and medical advice requests were reviewed independently by each author. Encounters where physicians managed the entire patient complaint through the MyChart portal were considered as separate electronic evaluation and management services of the patient's concern using the Centers for Medicare and Medicaid Services guidelines and thus potentially eligible for provider reimbursement.

There was a steady rise in patient-initiated MyChart encounters each year (Fig 1 ). Contact hours and patient clinic encounters also rose during this same period, but the rise in messages outpaced the time spent in face-to-face care (Fig 2 ). In our sample, 58% of the messages were medical advice requests, and 30.75% of all messages met criteria for separate evaluation and management services via the portal. Other categories of messages included 22% for appointment changes, 13.50% for history questionnaires, and 6.5% for medication refill requests.

Fig 1.

Patient MyChart encounters quantified. This figure shows the steady rise that was seen in the number of patient-initiated MyChart encounters each year, with a total increase of 17,745 between 2010 and 2018.

Fig 2.

Patient MyChart messages compared with provider contact hours and patient clinic encounters. Patient-initiated MyChart messages increased compared with provider contact hours and patient clinic encounters. The rise in messages outpaced the time spent in face-to-face care.

Centers for Medicare and Medicaid Services has reimbursed virtual encounters since 2019. For instance, Current Procedural Terminology (American Medical Association, Chicago, IL) code 99421-99423 reimburses for remote monitoring treatment management services for an established patient based on the length of time spent with the provider.³ The reimbursement is currently suggested at $15 for 5 to 10 minutes, $30 for 11 to 20 minutes, and $50 for ≥21 minutes.⁴ Most follow-up general dermatology clinic visits are billed with the Current Procedural Terminology code 99213, where providers may be reimbursed up to $150. A large disparity exists between proposed reimbursements for virtual vs face-to-face encounters that may carry the same level of liability and clinical decision making.

As a result of the novel coronavirus disease 2019 (COVID-19), effective March 6, 2020, Centers for Medicare and Medicaid Services will pay physicians for telehealth services at the same rate as in-office visits.⁵ Our study supports continuation of these policies after the social distancing measures of COVID-19 have ended.