Internet-Based Medical Second Opinion Services

Technical Report Internet-Based Medical Second Opinion Services Renato M.E. Sabbatini, PhD Center for Biomedical Informatics, State University of Campinas, Brazil November 1999 "Second opinion" is the term used in medical services for an additional consultation with another physician, required either by the attending physician or by the patient. Due to the increasing level of patient empowerment and knowledge, technical and scientific complexity of medical diagnostic and treatment procedures, and legal and economical issues, second opinion activities are on the rise everywhere. The Internet and the WWW have facilitated tremendously the deployment of on-line second opinion consulting services, particularly in the fields of medical images and tracings, specialized clinical and pathological diagnostic services, etc.; where the second physician is not required to see the patient in person. These services are usually fee-based and many health care plans have a provision to pay for them in the USA and other countries. Nowadays, many patients search the Internet for reassurance that their physicians have told them the right thing. The Internet gives to patients easy access to biomedical information, often providing them with a second opinion on their physicians' recommendations. For example, access to Medline, an on-line index of the original medical literature and research, is free for everyone and patients can read about the latest news and treatments from the same sources their physicians use for updating themselves. Thus, Internet information empowers patients and gives them a sense of control over their medical care. On the other hand, physicians are afraid that patients who think they know more about their diseases than the physician can be intimidating and difficult to treat. Despite their easy accessibility, it seems that on-line diagnoses and treatment plans will not replace or even diminish the central role physicians have in medical care, but rather complement it. Understanding well this new dynamics and providing on-line services in cue with what the market needs will be a very important consideration for the success of consumer-oriented health care portals on the Web. From the patient point of view, getting a second opinion regarding a medical condition or treatment can be expensive and time-consuming. In some cases, health plans may require a second opinion before the patient undergoes elective surgery. Minor conditions usually do not require a second opinion and are not likely to be covered by health plans, but in several cases a second opinion is warranted. However, patients have the right to ask for a second opinion even in less important cases. There are important economic factors involved in second opinion services, due to the following reasons; 1) uncontrolled second opinion has a potentially huge impact on payers' costs, when the patient is free to seek a second, third, etc. physician for the same ailments or services. Payers increasingly try to restrict the rights of patients to do this. 2) Well regulated second opinion services may actually save costs and increase the safety and quality of practiced medicine, because it avoids the consequences of medical errors and because Internet-based second opinion services, when allowed, are less expensive 1

than face-to-face second consultations (particularly when foreign specialists must be consulted). 3) Offering second opinion services for health care plan beneficiaries, particularly when using renowned institutions or foreign institutions as the back-ups, are very attractive in terms of marketing strategy. It is appropriate to seek advice from a second physician in the following circumstances (as recommended by the American Medical Association): 1. The attending physician spontaneously recommends a second opinion (this is rare); 2. The patient's condition is outside the primary physician's area of expertise; thus referral to a specialist is required (this is very frequent); 3. Elective surgery has been recommended. When surgery is not an emergency, a second opinion may be required by the health insurance plan (in the USA, at least. This is not common in other countries, but it should be). The patient might also want to know if there are treatment options other than surgery that would produce outcomes that are acceptable to him. 4. The physician hasn t reached a diagnosis, or the diagnosis isn t clear (this is very common in several specialties); 5. The physician has not been able to pinpoint the patient's diagnosis or he/she is not feeling better after several office visits. 6. The patient's medical condition is very rare or very serious, or requires a very lengthy or costly treatment. Before undergoing treatment, the patient wants to confirm the diagnosis with another specialist in the field. 7. The patient is not getting the information he/she needs from the physician. After trying to communicate with the physician, the patient still feels that he/she wasn't able to get all the information needed (this is the most common reason for the patient to access Internet-based "Ask the Doctor" services). Physicians know that second opinions are often required, and they know that patients sometimes need to seek an additional evaluation to feel comfortable. The patient always has the right to seek a second opinion, regardless of the doctor s opinion. The attending physician can give a referral for a second opinion, or the patient can find one by himself. Whether or not the patient asks the physician for a referral, it s best to let him or her know he's getting one. At that time, the patient can ask about the procedure for having his/her medical records, including the results of any tests that have already been performed, forwarded to the second doctor. Forms of Technology-Based Second Opinion Evidently, medical second opinion services have had a long history, and are as old as medicine itself. We are here specifically interested in distance second opinion, which in the past (and even today) has been largely based on the postal service and the telephone. In this kind of service, the consulting and the attending professional, as well as the patient, are located in different geographical locations. Technology-based second opinion uses more modern approaches, which can be classified into two distinct types: Real-time teleconferencing; specifically videoconferencing Store & Forward 2

Videoconferencing (VC) is a more expensive approach, requiring broadband communication (two-way analog or digital audio and video; using microwaves or ISDN lines, high-speed digital networks and switches, and so on) and specialized hardware and software. It can be either point-to-point or multipoint, and it is a highly effective tool for on-line, real-time visual and aural collaboration, exchange of information of several types and formats, etc. There are specialized medical peripherals, such as electronic stethoscopes and otoscopes, electrocardiographic machines, etc. In the USA and many countries, videoconferencing is considered a face-to-face encounter between physicians, and as such is a billable medical service. "Store & Forward" (S&F), on the other hand, does not require broadband, and is a simile of the postal service second opinion system. Information about a clinical or surgical case is gathered, digitized (images, test results, clinical case descriptions, tracings, etc.) and send to the consulting physician by means of a digital delivery system (email, FTP, Telnet, the Web, etc.). Therefore, interaction cannot be synchronous; although Internet-based or phone-based interaction may follow after information is received and both parties want to discuss it. Evidently, the cost of "Store & Forward" is much lower than videoconferencing, and this reflects in the fact that 80% or more of all second opinion interchanges in the USA are S&F and not VC. Case Studies Mammography Mammography is a specialized imaging procedure of the breasts. Its most used forms are planar x-ray films (obtained by means of a specialized equipment, the mamograph) and ultrasound mammography. CT and MRI mammographies are not used in the clinical routine yet, but are useful in difficult cases. Mammography is a $5 billion industry with over 35 million test performed annually in the United States. There are errors in the interpretation of these images. Up to 25% of scans may be interpreted incorrectly. Thus, all women who have been referred for breast biopsy based on the results of a mammogram should consider obtaining a second opinion prior to undergoing biopsy. National statistics show that approximately 80 percent of the one million biopsies performed annually in the US result in noncancerous (benign) findings. Expert mammography second opinion can help determine that biopsy is not needed in many cases. Women who have been referred for six-month follow up mammography should also consider a second opinion. A further value in the mammography tests primarily comes from being able to compare a previous scan with a current scan. A major problem in this aspect is that medical information is often scattered in multiple offices. The time to get the report to referring physicians and patients is extremely long. New federal legislation requires reports to be tracked and delivered promptly to the patient, yet many providers are not in compliance. Women are becoming more proactive and are demanding full access to their own medical information. 3

The outcome of a mammographic examination is very important from the point of view of physicians, patients and payers. Correct negative results may avoid expensive biopsies, surgery, high costs of therapy and hospitalization, human suffering and health and life crises. Correct positive results can save patient's lives and also many costs, incurred by a too-late intervention. The American College of Radiology (ACR) has developed a system called BI-RADS to help radiologists categorize mammography findings and guide the breast cancer diagnostic routine. If a mammogram case has been categorized as level 3 (probably benign) or level 4 (suspicious), mammography expert second opinion can help determine if biopsy is necessary. Learn more about the BIRADS mammography categorization system to help determine if mammography second opinion is appropriate in your case. All these factors have converged to make profitable a technology-based mammographic second opinion service. In the USA, several have hospital services and at least one specialized company has begun operation in this area. Medizeus www.medizeus.com Formally launched in October 99, Medizeus is an Atlanta, GA, based company which serves as an electronic intermediary for mammography image data and diagnostic reports, speeding the flow of information between mammography clinics, radiologists, referring physicians and patients. Using advanced Internet technology, the company transforms a multi-step paper- based process into a more efficient and faster electronic one. While speeding up the flow of information, Medizeus also boosts accuracy by offering medical personnel a computerized "second opinion" from an advanced artificial intelligence system (automated image interpretation and reporting). There are multiple advantages for each person in the healthcare sector. For the doctors - - both referring physicians and radiologists -- it increases the accuracy so they are practicing better medicine, and it increases their efficiency, so they can get more reports out in less time. By using an electronic system, there are also savings in record-keeping and report writing." Patients will also be able to access their medical records from anywhere in the world. Archiving this data will make baseline reports readily available even when patients change physicians. Its archived mammogram data will also allow Medizeus to support research studies on test frequency and benefits. Mammogram images produced in clinics scattered around the area are sent to Medizeus electronically. The company forwards them to participating radiologists, who analyze the images and attach their diagnostic reports to the image file. Physicians then use a Web-based interface to view the images and reports. The information can be sent electronically to billers, and also becomes available to patients using the same Webbased interface. 4

Medizeus provides connectivity for all these groups at Internet Speed. In the past, radiologists have been tied to a specific clinic because they had to read images on film. With the digital technology, they won't necessarily have to be in the same facility where the mammograms are done. This may allow a radiologist to serve six clinics instead of one. " Medizeus' products and services provide benefits for medical providers, payers and patients. A radiologist using RapidReport overhead costs and increases throughput of patient cases. Payers can purchase analytical outcomes reports developed from the Medizeus database. Patients will have confidential access to their own medical records anytime, anywhere. The management team is composed of individuals with extensive medical and business experience. David N. Ku, MD, PhD, Co-Founder - Dr. Ku spearheads Medizeus' strategic, organizational, and technology development. Dr. Ku is a Regents' Professor of Mechanical Engineering at Georgia Tech and a Professor of Surgery at Emory University. In addition to his experience as a practicing physician, researcher, and professor, he is the founder of a successful medical device startup company, Restore Therapeutics. Harris L. Bergman, PhD, Co-Founder - Dr. Bergman directs Medizeus' Internet infrastructure and created Medizeus' proprietary analytical software. He is an expert in artificial intelligence, medical imaging, and high-performance computing applications. He holds a PhD from Georgia Tech, where he won a prestigious National Science Foundation Fellowship. University of North Carolina Breast Imaging Center Mammography Expert 2nd Opinion Service http://www.imaginis.net/2ndopinion/ The UNC Mammography Second Opinion Service provides expert interpretation of mammograms or other breast cancer diagnostic studies such as breast ultrasound or breast MRI. The service is especially useful for mammography cases where breast cancer is suspected but not confirmed. The service is provided by the University of North Carolina Breast Imaging Team headed by Dr. Etta Pisano, a world-class breastimaging specialist. The UNC Breast Imaging Team has helped women and physicians all over the United States with the expert interpretation of their mammograms. This service is easy to use. 1. Register to use the service. Once you have registered, the user receives a confirmation and medical record number. 2. The user send his current mammography films and radiologist report to the UNC Breast Imaging Team. 3. The UNC Breast Imaging Team carefully reviews the case, renders the second opinion and generates a written report within seven business days. The films and a print copy of the second opinion report are returned by postal mail. Any woman who has been referred for a breast biopsy should consider having a second opinion. Any woman who is worried about the results of her mammogram may get a 5

second opinion. Any woman or doctor who requires expert interpretation of a mammogram or other breast-imaging exam may use the second opinion service. The Mammography Expert Second Opinion Service costs $75 for the interpretation of a mammogram study. Costs for mailing the mammogram films are the user's responsibility. If there are both mammogram and ultrasound images to be interpreted, the charge is $150.00 (US). Second opinion service for interpretation of breast MR images (MR mammography) is available for $200 (US) per case. Most insurance companies, HMOs and healthcare providers will reimburse for the cost of the second opinion. However, the patient is responsible for submitting the proper paper work to her insurance company or health plan for reimbursement. Miami Medical Center Second Opinion System The MMC Second Opinion Program, created over four years ago, allows someone in a foreign country to obtain a second opinion from a US physician without the need to travel. The program uses one of the following mediums to transfer the medical records and diagnostic images to the United States: Video-Conference: Using MMC s proprietary Telemedicine System MTS 2320 installed in Argentina, Mexico and Peru, the patient or his or her physician can have a video conference a described above. The system is composed of high-resolution peripherals, such as a Leitz microscope, attached to a personal computer. Store & Forward: Using the MTS 2320 or other approved system, medical images can be captured and sent via the Internet (protected by strong encryption) or by a direct telephone connection to MMC s offices in Miami. MMC representatives then send the images to the most appropriate specialist anywhere in the United States. The physician reviews the records and sends his medical opinion via email or fax within 24 hours. Courier: This medium follows the same steps as the "Store & Forward" but using a courier such as FedEx or DHL instead of the MTS 2320 and email. The MMC Telemedicine System was created exclusively for patient consultations. Our system was developed to improve the second opinion system that MMC used a few years ago which operated with overnight couriers, faxes and telephone conversations between patients in Latin America and physicians in the U.S. The program is not restricted to MMC enrollees. The Telemedicine System is available to the general public for a fee that varies by country, by method used (courier, videoconference, etc.), by physician and by illness. Second Opinion in Radiology Radiology Department of the Virchow Klinikum, Humboldt University, Berlin, Germany Requests for second opinion in the area of Radiology can be sent through E-mail. The patient may include images, documentation and related material, enclosed as attachments. 6

The service is offered by Strahlenklinik und Poliklinik (Director: Prof. Dr. Dr. h.c. R. Felix) Virchow Klinikum Medical Faculty, Humboldt University Berlin. The following images can be processed: 1. Imaging systems integrated to the hospital's local network: send images of any digital imaging source in original format (ACR/NEMA or Dicom) attached to the electronic mail. ACR/NEMA and DICOM are not supported as a standard MIME image format. To make automatic identification possible on the recipients side, a couple of changes need to be done to the configuration of the sending application, since otherwise our mail viewer may not be able to identify MIME-encoded files. 2.Hardcopies of radiological images, scanning with a CCD-scanner: applicable for any kind of image. Send images in standard multimedia formats (e.g. GIF, TIFF, and JPEG). Mammographies most likely will have limited quality. 3.Scanning with a document camera: only applicable for CT or MRI images. Information loss will occur for any conventional x-ray (most cameras do not handle the number of gray shades displayed on conventional radiographs). Send images in standard multimedia formats. Bibliography American Medical Association. General Health Services. Getting a Second Opinion. http://www.ama-assn.org/insight/gen_hlth/doctor/second.htm HealthCentral: Cyberdocs may be bad for your health. http://www.healthcentral.com/news/newsfulltext.cfm?date=11/6/1998&title=cyberdoc s%20may%20be%20bad%20for%20your%20health&id=6859 Ramires, L.: Doubtful information on health Web sites can be hazardous. Kansas City Star, 7/13/99. http://www.kcstar.com/item/pages/home.pat,local/3773af69.713,.html Duckett, Thomas, MD: Second Opinion on the Net. Sonoma County Medical Association, 1996. http://scma.org/scp/scp960102/duckett.html Getting a Second Opinion. http://merritt-gentry.com/freefiles/files/b1510.htm Internet Resources Karolinska Institutet: Ask the Doctor & Second Opinion Services Index. http://www.mic.ki.se/diseases/askdoc.html An index of topic-categorized links to services that offer expert advise, support services, professional information retrieval, etc. Software Products for Second Opinion Systems Second Opinion: http://www.2opinion.com 7