Rambam Medical Center
Illustration: Emergency room at Rambam Medical Center, Haifa. Photo by Hagai Frid
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Turning to journalist Gideon Reicher in a new commercial video clip by the Clalit health maintenance organization, a cartoon character smiles and says, "I didn't rush and I didn't run around." The clip, starring Hamudi, one of the HMO's mascots, presents new digital services offered by Clalit to its insurees - making it possible to use the Internet to renew prescriptions, and to request referrals to specialists, a variety of permits, consultation with experts and personally adapted medical advice. The HMO plans to expand the service so that, in half a year's time, insurees will be able to see their entire personal medical file online, including hospitalization in Clalit hospitals.

The online service has been in operation for more than half a year, but only now, after the commercial, are doctors in the field complaining that it is causing a dramatic change for the worse in doctor-patient relations in the country's largest HMO, which insures 3.9 million people. The Israel Association of Family Physicians has been voicing serious concerns in recent weeks. The family doctors are afraid the service is downgrading their professional status.

"Notice how they're marketing us," a senior family doctor warned recently in correspondence among association members. "You no longer have to go to the doctor - the clerk in the branch will do what you ask via the Internet. Do you feel comfortable with such a method of advertising doctors/clerks? What has happened to the relationship between a doctor and his patient, when we're being marketed this way?"

Another doctor said, "It's true that the service makes it possible to ask patients to come [to the clinic], but isn't it a waste of our time? Isn't it better for us to invest it in treating patients? In consultations? Isn't it a shame to have all the unnecessary 'arguments' with patients that Hamudi promised them?"

A third protested the separation between staff in clinics and those engaged in administration, computerization and marketing in the HMO. "Has any of them recently visited a clinic and seen the overcrowding? How can you market 21st-century medicine to patients when the workload doesn't even make 1980s medicine possible? Do they want loads of customers? Make the experience of visiting a clinic more tolerable."

One of the doctors even called on the others to consider refusing to cooperate with the step, "to refuse to work contrary to medical considerations and our conscience," as he put it. A family doctor summed up by saying that "this campaign and others continue to destroy the image of the expert family doctor, which was created with great effort - the doctor who specialized for years and is a professional in his field and provides good medical care for his patients - and to advance the image of the 'general practitioner,' who did not specialize in family medicine, and to whom you go only to receive referrals, that's his job, isn't it? It's really very sad."

The Association of Family Physicians recently began a reexamination of the service. At a recent conference, they presented a position paper explaining the functions of the family doctor. The paper, which was written by the association's secretary, Dr. Michal Shani, says that "there is room for online work alongside a family doctor, as well as for the use of various technologies," but the association believes there should be limitations.

The association's chairman, Prof. Shlomo Vinker, says that "Internet medicine is good when it's done in moderation. What makes me uncomfortable is the services that are unsuited to the Internet - for example, if someone asks the doctor to recommend him for a fitness club or for advice about heart palpitations."

In certain cases the association agrees that Internet medicine can be promoted - for example, when a patient whom the doctor knows well asks for an extension of a prescription, or a patient who received a two-day sick leave needs another day, there's no reason not to do this online rather than making these patients wait in line at the clinic.

'Medicine has to change'

The Association of Family Physicians wants to enable doctors in the field to decide for themselves whether or not to join the online service. "There are doctors who want to see the patient for everything and we have to respect that," says Vinker. "If that doesn't suit the patient, he can almost always transfer to another doctor."

The Clalit doctors committee claims to have forms that enable doctors to remove themselves from Internet service, and that several family doctors have asked recently to be removed from the new online service. But the Clalit administration explains that online medicine is essential and that there are even plans to expand it in the near future.

"There are many changes in the technological age, with exposure to the Internet and to social networks, so there's no choice - the change has to come to medicine as well," says Clalit's deputy director and director of its community health division, Dr. Orit Jacobson. "It's like in gynecology - until three or four years ago not every gynecologist had a sonogram machine, and today the device is essential in every gynecology clinic. So if there were doctors who had difficulty using it, we taught them. In online medicine, too, if there are doctors who find the change difficult, we'll support them."

Jacobson says, "We have to suit the service to a new generation that wants quick answers and quick service. Medicine is no different from other services, such as those of an electric company or a bank. In medicine we're more cautious, but it's important to make information available to the patient as much as possible. Why can you get forms on the Internet today from any government institution, and only in medicine will people have to continue visiting the clinic and waiting in line? In such a situation the patient will also develop greater responsibility for his health."

The Internet services at Clalit have undergone several upheavals. "At the moment we're offering only specific services, such as renewing a prescription or requesting an urgent house call," says Jacobson. "With these services, too, the doctor has the option of asking the patient to come to the clinic. For example, in order to renew a prescription, the doctor has to look at the patient's medical file and if he sees anything out of the ordinary in a laboratory test, or if the patient hasn't visited him for a long time, there's no automatic renewal. But the doctor has an obligation to say, 'I'm not renewing the prescription, come for a checkup.' We fully support a doctor who decides for justified reasons not to respond to an insuree's request."

Increasing workload

In the wake of opposition, the HMO administration has decided at this point not to include sick-leave requests in the services offered via the Internet. Jacobson says, "This is a process that we plan to expand gradually, and we definitely intend to offer sick-leave permits in the future."

An additional expansion is planned in half a year, when Clalit insurees will be able to see their computerized medical files. According to Jacobson, "We have a large number of insurees who have been under our care for 50 and 60 years. It's not possible that there's no mistake in some file. We prefer to go with an open process, to take responsibility and to ask patients to peruse the files and to check whether there's a mistaken diagnosis. It's a step that's being taken in the interest of transparency."

It's hard to avoid mentioning the financial aspect of the move. The Internet service is likely to lead to a significant increase in online requests to Clalit doctors, which will increase their workload. The doctors are asking for suitable compensation. "A doctor can receive another 30 requests at the end of a workday from various places - via the Internet, phone calls and people who have 'popped in' to the clinic," says Vinker. "The question is whether he has to stay after hours."

As opposed to rival HMO Maccabi, which relies on independent doctors who receive payment according to the number of patients coming to the clinic, in Clalit most doctors are salaried and receive payment according to the number of patients listed for each doctor. That is why a change in the system should not affect their paycheck. "In the context of the salary agreement with the doctors, whose implementation begins in February," says Jacobson, "additional time is allotted after office hours to respond to Internet and other requests."

Dr. Baruch Itzhak, head of a committee of community health doctors in Clalit, says the committee is working in coordination with the Association of Family Physicians regarding the contents of online medicine. "We support Internet medicine, when it's done in the right dosage and with the proper structure," he says. "It must be restricted to matters that don't require physical contact with the patient, without undermining privacy and the Patients' Rights Law, and there is agreement between us and the Israel Medical Association that the use of online medicine is up to the doctor's judgment."