Physicians Slow to E-mail Routinely with Patients

Issue Brief No. 134

October 2010

Ellyn R. Boukus, Joy M. Grossman, Ann S. O'Malley

A number of experts consider e-mail exchanges between doctors and patients a promising mechanism for strengthening physician-patient communication and, in turn, enhancing the quality of patient care. Although surveys suggest that a substantial proportion of patients desire the ability to e-mail their doctors, physician uptake of e-mail for patient communication continues to be uncommon — just 6.7 percent of office-based physicians routinely communicated with patients via e-mail in 2008, based on a new nationally representative study from the Center for Studying Health System Change (HSC). In total, roughly one-third of office-based physicians indicated that information technology (IT) was available in their practice to support e-mail communication with patients regarding clinical matters. Among those with access, less than one in five reported using e-mail with patients on a routine basis; the rest were divided approximately equally between those who used it occasionally and those who did not use it at all. Physicians practicing in settings with electronic medical records and those employed by health maintenance organizations (HMOs) or academic medical centers were more inclined to adopt and utilize e-mail for patient communication relative to other physicians. Nevertheless, even among the most frequent users — physicians in group/staff-model HMOs — only 50.6 percent reported routinely e-mailing patients.

Physician Adoption and Use of E-mail Remains Low

E-mail between doctors and patients has been characterized by some observers as a means to improve communication, foster greater patient engagement and satisfaction, enhance patient outcomes and care quality, and increase efficiency. Several recent investigations have shown favorable effects of patient-provider e-mail across each of these areas, though the evidence base generally centers on specific patient populations, such as individuals with diabetes, or particular practice environments, such as integrated delivery systems. [1] Furthermore, public opinion research indicates that patients are eager and prepared to interact with their physicians through e-mail. A survey fielded at the close of 2009 revealed that between 50 percent and 70 percent of adults who had not yet used e-mail to communicate with their doctors or nurses expressed interest in doing so. [2] Even so, only 8 percent of all adults surveyed reported having ever sent or received an e-mail with their physician. [3]

Although patients seem willing to embrace e-mail, physicians are considerably less prepared to do so, based on results from the nationally representative HSC 2008 Health Tracking Physician Survey. A mere 34.5 percent of U.S. physicians delivering office-based ambulatory care in 2008 reported that their practice had IT capabilities for e-mailing patients about clinical issues (see Figure 1 and Data Source). Among physicians with e-mail access, fewer than one in five (19.5%) used e-mail on a routine basis to discuss clinical matters with patients. Across all office-based physicians nationally, only 6.7 percent routinely e-mailed patients in 2008. By comparison, e-mail communication with fellow providers was substantially more prevalent: twice as many physicians devoted at least some portion of each workday to e-mailing other physicians and clinicians as compared with e-mailing patients and their families (findings not shown).

Overcoming Barriers

Physician apprehensions about the absence of reimbursement, the possibility of heightened workload, safeguarding data privacy and security, avoiding greater medical liability exposure, and uncertainty regarding effects on care quality are frequently identified as factors that may deter physicians from embracing e-mail. [4] Policy makers are actively weighing strategies to promote the adoption of secure online communications between physicians and patients — for instance, through endorsement of the patient-centered medical home model or through Medicare and Medicaid payment incentives linked to "meaningful use" of health IT.

The HSC survey inquired about whether e-mail for communicating with patients was available in the physician's practice but did not determine what specific types of e-mail tools were in use. Policy makers have concentrated on the adoption of secure electronic messaging that complies with the Health Insurance Portability and Accountability Act (HIPAA) privacy and security requirements. The survey estimates, however, do not distinguish among a wide array of electronic communication tools encompassing both traditional unencrypted e-mail and secure Web-based messaging platforms. The latter may be embedded within more advanced systems, such as patient portals that also support functions like prescription refill requests, online appointment scheduling, and medical records access, and may or may not be integrated with electronic medical record (EMR) systems. [5] Certain more technically sophisticated platforms also may facilitate real-time virtual consultations that can serve as alternatives to in-person visits, extending beyond the asynchronous exchange of messages between patients and physicians. [6]

The survey questions also did not address whether other practice staff, besides the physician, communicated with patients electronically about clinical concerns. Practices differ considerably in how they deploy electronic communication tools: in some settings, office staff may screen and triage e-mail inquiries, thereby reducing the volume of messages requiring a direct physician response. [7] As a result, the study findings may undercount the degree to which physician practice staff, in a broader sense, utilized electronic communication tools with patients.

E-mail Among Least Used Clinical IT

The limited prevalence of physician-patient e-mail is even more striking when viewed alongside other forms of IT in physician practices, particularly given the generally low rates of health IT uptake among providers. Of 16 clinical tasks that can be supported by IT about which physicians were surveyed, e-mail communication with patients ranked third from the bottom in terms of availability and dead last with respect to routine use (see Figure 2 for selected clinical tasks). Nearly 35 percent of all physicians had e-mail capabilities in their practice, while just 6.7 percent routinely made use of the technology. In contrast, 76.6 percent of physicians had IT for viewing laboratory and other diagnostic test results, and 61.8 percent used that technology on a routine basis.

Physicians in practices equipped with fully electronic EMRs were more than twice as likely to report having e-mail access and more than three times as likely to use it routinely for patient communication when it was available, relative to physicians in practices relying exclusively on paper records (see Table 1). Although physician-patient e-mail tools have not traditionally been part of the core functionality of EMR systems, practices with EMRs can deploy add-on secure messaging tools or multi-function patient portals. Integrating patient communication tools with EMRs can present challenges, but having an EMR may facilitate more efficient and effective e-mail use and documentation in the patient's medical record than relying on stand-alone e-mail tools with paper charts. [8] This added convenience may help ensure that e-mail does not become merely another inbox for physicians to monitor for incoming messages. EMR adoption in a practice may also indicate greater physician comfort with and openness to using other clinical IT, including e-mail, with patients.

Routine Use of E-mail Low Across Practice Settings

Although e-mail availability increased with practice size, there was minimal variation in routine use, with the exception of physicians in group/staff model HMOs. This stands in contrast to other categories of health IT, such as electronic prescribing, where both adoption and utilization differ across practice settings. [9] Even in HMOs, where more than 81 percent of physicians reported that e-mail was available in their practices, only approximately half of those physicians used it on a routine basis. By comparison, in solo and two-physician practices, 27.2 percent of physicians reported e-mail was available, and among those, only 13.6 percent used it routinely. Physicians in medical school-based settings also were more likely to have e-mail access (57.8%) and to use it routinely when available (25.9%) compared with physicians in solo and two-physician practices, though the differences were less marked than for physicians employed in HMOs.

The higher prevalence and — in certain instances — greater use of e-mail among physicians in large group, group/staff HMOs, and academic medical practices may be partly attributable to other factors, including the elevated rate of EMR adoption in those environments. However, disparities in e-mail adoption and use persisted even when the analysis was restricted to physicians in practices relying exclusively on EMRs (findings not shown).

In general, larger practices — especially those within integrated delivery systems — are more likely to command the resources necessary to invest in technological innovations aimed at improving workflow and transforming ambulatory care delivery. For example, large group/staff-model HMOs, such as Kaiser Permanente and Group Health Cooperative, have implemented electronic messaging through patient portals. [10]

Although there was little variation in adoption across specialties, general internists were more likely to use e-mail routinely compared with physicians in other specialties. Relative to their younger peers, physicians over the age of 55 were less likely to have e-mail available, and those who did have access were roughly half as likely to employ it routinely for patient communication. This pattern may reflect both age-related factors and work environment, since older physicians tend to practice in smaller settings that are less likely to be outfitted with IT. When smaller and larger practices were examined separately, comparisons of physicians across age groups showed no differences in adoption, yet older physicians on average remained approximately half as likely to use e-mail routinely as their younger colleagues (findings not shown). This may indicate that decisions about technology adoption are made at the practice level, whereas the choice to actually use the technology may be left to individual physicians.

Financial incentives also may influence the adoption or avoidance of e-mail: physicians receiving a fixed salary used e-mail more frequently than those compensated through other arrangements. Salaried physicians may engage in more patient communication generally, including via e-mail, because they can dedicate more time to activities that are not directly tied to reimbursement, unlike physicians facing revenue-based or productivity-based incentives. While physicians in larger practices and group/staff-model HMOs were more likely to be salaried, these differences in e-mail use persisted after controlling for practice size and setting.

Patients in nonmetropolitan areas who must travel long distances to receive care could potentially benefit greatly from e-mail interactions because of the potential to save travel time. However, physicians practicing in nonmetropolitan areas were less likely to have access to e-mail and roughly half as likely to use it routinely when it was available compared with providers in metropolitan areas. This may partly reflect differences in practice size, setting, and available resources. Yet, these disparities remained even after accounting for the lower likelihood of physicians in nonmetropolitan areas working in larger practices or having EMRs available.

Physician Concerns Pose Barriers to Widespread Adoption

Physician worries about increased workload without corresponding reimbursement, uncertainty regarding effects on care quality, and difficulties related to data privacy and security and medical liability have impeded the adoption and use of e-mail for patient communication. Federal policy initiatives currently in progress to support delivery system reforms may help stimulate physician adoption and use of e-mail communication with patients indirectly.

In July 2010, the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology issued final rules implementing provisions of the American Recovery and Reinvestment Act of 2009 concerning Medicare and Medicaid incentive payments tied to the "meaningful use" of EMRs. While the incentives are not currently linked specifically to electronic communication with patients, the growth in EMR use spurred by these incentives may at least indirectly encourage e-mail adoption and use to the degree that electronic messaging tools are integrated or deployed in conjunction with EMRs, for the reasons outlined earlier.

The Medicare and Medicaid incentive programs additionally require that physicians utilize EMRs meeting standards designed to protect privacy and safeguard personal health information. To the extent that electronic communication is linked with EMR use, these standards may help to alleviate physicians' anxieties about data security. Moreover, formal protocols governing message triage, response turnaround time, appropriate use, and documentation can help address physicians' liability concerns. [11]

While EMRs may facilitate the adoption of e-mail — and findings from the 2008 Health Tracking Physician Survey indicate that the two are indeed correlated — this is not an assured outcome. Furthermore, the question persists whether physicians will actually use e-mail without additional reimbursement for the extra costs associated with communicating with patients electronically to better coordinate patient care. [12] As Medicare and Medicaid "meaningful use" requirements escalate as planned in subsequent stages of the program's rollout, policy makers may revisit earlier proposals to mandate the adoption of secure patient-provider messaging capabilities as a condition for receiving future incentives. [13] The anticipation of such requirements may motivate some practices to adopt electronic communication sooner rather than later.

In the interim, certain health plans and physician practices have begun experimenting with different payment models to encourage e-mail communication with patients. Aetna and CIGNA are reimbursing providers nationwide for virtual visits, or "e-visits," including the use of secure messaging and real-time online consultations, on a per-visit basis. [14] An alternative approach is to reimburse providers on a capitated, or fixed fee per patient, basis for conducting a broader array of care coordination activities that improve communication with patients, as envisioned in the patient-centered medical home. [15] Yet another option is to charge patients annual fees for access to e-mail consultations with physicians. Patients may be willing to bear the additional cost in exchange for time and travel savings and greater convenience. Moreover, the cost of electronic correspondence might be lower than what patients would pay for an in-person visit. [16]

Ultimately, policy makers and researchers should more systematically investigate whether e-mail or other secure electronic communication with patients can fulfill its promise to strengthen communication, increase patient engagement and satisfaction, improve patient outcomes and care quality, and enhance efficiency. If e-mail does deliver on these goals, expanding incentives to promote e-mail communication between physicians and patients may prove to be a worthwhile investment.

Notes

1. Houston, Thomas K., et al., "Experiences of Patients Who Were Early Adopters of Electronic Communication With Their Physician: Satisfaction, Benefits, and Concerns," American Journal of Managed Care, Vol. 10, No. 9 (September 2004); Harris, Lynne T., et al., "Diabetes Quality of Care and Outpatient Utilization Associated with Electronic Patient-Provider Messaging: A Cross-Sectional Analysis," Diabetes Care, Vol. 32, No. 7 (July 2009); Rosen, Paul, and C. Kent Kwoh, "Patient-Physician E-mail: An Opportunity to Transform Pediatric Health Care Delivery," Pediatrics, Vol. 120, No. 4 (October 2007); Liederman, Eric M., et al., "The Impact of Patient-Physician Web Messaging on Provider Productivity," Journal of Healthcare Information Management, Vol. 19, No. 2 (Spring 2005).

2. Fifty percent of adults who did not use personal health records (PHRs) were somewhat or very interested in sending an e-mail to, or getting an e-mail from, a doctor or nurse. Sixty-nine percent of adult PHR users who had not done so were interested in this feature. See California HealthCare Foundation, Consumers and Health Information Technology: A National Survey (April 2010).

3. Ibid.

4. Katz, Steven J., and Cheryl A. Moyer, "The Emerging Role of Online Communication Between Patients and Their Providers," Journal of General Internal Medicine, Vol. 19, No. 9 (September 2004).

5. Dixon, Ronald F., "Enhancing Primary Care Through Online Communication," Health Affairs, Vol. 29, No. 7 (July 2010).

6. Whitten, Pamela, Lorraine Buis and Brad Love, "Physician-Patient e-Visit Programs: Implementation and Appropriateness," Disease Management and Health Outcomes, Vol. 15, No. 4 (2007).

7. McCarthy, Douglas, Kimberly Mueller and Ingrid Tillman, Group Health Cooperative: Reinventing Primary Care by Connecting Patients with a Medical Home, Commonwealth Fund (July 2009).

8. California HealthCare Foundation, Online Patient-Provider Communication Tools: An Overview (November 2003).

9. Grossman, Joy M., Even When Physicians Adopt E-Prescribing, Use of Advanced Features Lags, Issue Brief No. 133, Center for Studying Health System Change, Washington, D.C. (July 2010).

10. Harris, et al. (2009); Chen, Catherine, et al., "The Kaiser Permanente Electronic Health Record: Transforming and Streamlining Modalities of Care," Health Affairs, Vol. 28, No. 2 (March/April 2009).

11. American Medical Association, Guidelines for Physician-Patient Electronic Communication, http://www.ama-assn.org (accessed on Sept. 3, 2010).

12. Katz and Moyer (2004).

13. U.S. Department of Health and Human Services, Health IT Policy Council Recommendations to National Coordinator for Defining Meaningful Use (August 2009).

14. Gearon, Christopher J., "Take Two and E-mail Me at Your Convenience," AHIP Coverage (July/August 2008).

15. Patient-Centered Primary Care Collaborative, Joint Principles of the Patient Centered Medical Home (February 2007).

16. Lowes, Robert, "Getting Paid for Mouse Calls," Physicians Practice (March 2009); Dixon (2010).

Data Source

This Issue Brief draws on findings from the HSC 2008 Health Tracking Physician Survey, a nationally representative mail survey of U.S. physicians. The physician sample was derived from the American Medical Association master file and encompassed active, nonfederal, office- and hospital-based physicians who provided a minimum of 20 hours per week of direct patient care. Residents and fellows were excluded from participation, as were radiologists, anesthesiologists, and pathologists. The survey captured responses from more than 4,700 physicians and achieved a 62 percent response rate. Because this Issue Brief concentrates on e-mail use in the outpatient setting, physicians who reported practicing as hospitalists or treating patients in hospital emergency departments were excluded from this analysis. The resulting analytic sample comprises 4,258 physicians. Estimates from this survey should not be compared to estimates from HSC's earlier Community Tracking Study Physician Surveys owing to changes in survey administration mode from telephone to mail, question wording, skip patterns, and sample structure.

Physicians were asked, "Is information technology available in your practice to communicate about clinical issues with patient by e-mail?" If the response was "yes," physicians were further asked, "How often do you personally use the technology?" The response categories provided were "routinely," "occasionally," or "not at all." Physicians were also asked, "Does your main practice use electronic medical records?" The response categories were "yes, all electronic," "yes, part electronic and part paper," and "no, all paper."

More detailed information on survey content and methodology can be found at www.hschange.org.

Funding Acknowledgement

The 2008 HSC Health Tracking Physician Survey and this research were funded by the Robert Wood Johnson Foundation.

Sources and Further Reading

ONC Meaningful Use and Health IT Adoption — Background on the Medicare and Medicaid EHR meaningful use incentive programs that shaped physician adoption of electronic communication tools.

CMS Promoting Interoperability Programs — Details on Medicare and Medicaid incentive payments tied to health IT use, including electronic messaging with patients.

Health Affairs: Enhancing Primary Care Through Online Communication — Peer-reviewed research on the role of patient-physician electronic communication in primary care delivery, cited in this study.

AMA Guidelines on Electronic Patient-Physician Communication — American Medical Association guidance on the ethical and practical aspects of electronic communication between doctors and patients.

Robert Wood Johnson Foundation — Funder of the HSC Health Tracking Physician Survey and the research underlying this study on physician email adoption.