Physicians Slow to Adopt Patient E-mail

Physician Adoption of Patient E-mail Remained Low Despite Growing Demand

By the mid-2000s, two major health care trends — the push toward consumerism and the spread of health information technology — were converging around a single question: could electronic communication between doctors and patients improve how people managed their care? The American Health Information Community (AHIC), a federal advisory commission formed during this period, singled out secure online messaging between physicians and patients, especially those living with chronic conditions, as one of a small number of "breakthrough" technologies earmarked for rapid development. Public polls reinforced the demand, showing that 80 percent of Americans who used the internet wanted the option of communicating with their doctors through e-mail.

Yet the reality on the ground told a different story. Physicians were adopting patient e-mail at a sluggish pace. According to data from HSC's nationally representative Community Tracking Study (CTS) Physician Survey, only about one in four physicians (24 percent) reported that e-mail was used in their practice to discuss clinical matters with patients in 2004-05, up from roughly one in five in 2000-01. That 20 percent growth rate fell behind the pace at which physicians were adopting other clinical IT tools, including electronic prescribing and digital access to patient records.

Beyond Traditional E-mail: Secure Messaging Platforms

It is worth noting that the tools available for physician-patient electronic communication had expanded well beyond standard unencrypted e-mail. Encrypted e-mail services, Web-based patient portals, and messaging features built into electronic medical record (EMR) systems all offered more secure alternatives. Federal policy strongly favored secure platforms, but the CTS survey estimates captured adoption of the full range of both secure and unsecure messaging tools used in physician practices.

The Payment Problem

The absence of reimbursement for e-mail consultations stood out as a major obstacle to wider adoption. A handful of health plans were experimenting with paying physicians for electronic consultations, but these arrangements were limited in scope. Some practices tried charging patients directly for e-mail interactions, though it remained unclear how much patients would be willing to pay out of pocket for the service.

The cost barrier was especially relevant for secure messaging systems, which required greater investment than simple unencrypted e-mail. Without payment for electronic consultations, few physicians were inclined to absorb that expense. Beyond reimbursement, physicians worried that e-mail would pile onto their existing workload rather than replace in-person or telephone interactions. While some studies had demonstrated that e-mail could improve practice efficiency and patient satisfaction through more timely communication, the evidence on its effects on care quality remained thin.

Growth Stalled in Larger Practices

E-mail adoption tracked closely with practice size. In 2004-05, physicians in staff or group-model health maintenance organizations (HMOs) and medical school faculty practices reported the highest rates of patient e-mail use, at 47 percent and 43 percent respectively. Group practices with more than 50 physicians followed at 29 percent. Smaller practices lagged behind: only about 20 percent of physicians in practices with nine or fewer doctors reported e-mail use.

A troubling pattern emerged between the two survey rounds, however. Growth in e-mail adoption essentially stalled among larger practices between 2000-01 and 2004-05. During that same interval, smaller practices with nine or fewer physicians did show statistically significant growth. The fact that large practices — which had historically been early adopters of clinical IT — were no longer expanding their e-mail use suggested that the technology was not gaining traction in the way policy makers had hoped.

Digital Divide Among Patient Populations

One factor that distinguished physician decisions about e-mail from other clinical IT adoption was the requirement that patients also be able and willing to use the technology. Rural residents, low-income populations, elderly patients, and African-American consumers were all less likely to have internet access, and among those who did, many used e-mail less frequently. Practices serving higher concentrations of these populations may have moved more cautiously toward offering e-mail consultations, given more limited patient demand and digital literacy.

The survey data confirmed these dynamics. Physicians in nonmetropolitan areas were significantly less likely to report e-mail use than their metropolitan counterparts (11 percent vs. 26 percent in 2004-05), and the gap had not narrowed over the survey period. Practices that drew more than 25 percent of their revenue from Medicaid also showed lower e-mail adoption, with no statistically significant growth between survey rounds. The same stagnation appeared in practices where Medicare accounted for more than half of revenue.

Variation by Specialty and Physician Age

Adoption patterns also differed across medical specialties. Primary care physicians reported 24 percent e-mail use in 2004-05, up significantly from 18 percent in 2000-01. Surgical specialists showed the highest rate among the three specialty categories at 28 percent, also a significant increase from 23 percent. Medical specialists showed the weakest growth, moving from 20 to 22 percent, a change that did not reach statistical significance.

Physician age played a role as well, though not in entirely predictable ways. Physicians younger than 35 reported 20 percent e-mail use in 2004-05, and the change from 18 percent in 2000-01 was not statistically significant. Physicians aged 35 to 54 showed significant growth, from 21 to 25 percent. Physicians older than 54 saw the largest jump, from 17 to 24 percent, suggesting that older doctors were catching up to their younger colleagues on this particular technology.

Interpreting the Survey Data

An important caveat applied to these findings. The CTS survey asked physicians whether e-mail was used in their practice to discuss clinical issues with patients, but did not ask whether the responding physician personally used it or how frequently it was used. As a result, the reported figures should be understood as an upper bound on the proportion of physicians regularly communicating with patients electronically. The actual rate of sustained, individual physician use was likely somewhat lower.

A Slow March Toward Digital Communication

The overall picture painted by this research was one of modest, uneven progress. Federal policy makers had identified secure physician-patient messaging as a high-priority goal, and patient demand was strong. But a combination of payment gaps, workflow concerns, uneven patient digital access, and the stalling of growth in precisely the practice settings that had been expected to lead the way meant that widespread adoption remained a distant prospect. Without meaningful reimbursement for electronic consultations and broader patient access to the internet, physician-patient e-mail was unlikely to realize the potential that advocates envisioned for it.

About the Data

This Data Bulletin drew on findings from the HSC Community Tracking Study Physician Survey, a nationally representative telephone survey of physicians in direct patient care across the continental United States. The survey was fielded in four rounds: 1996-97, 1998-99, 2000-01, and 2004-05. Physicians were sampled from the American Medical Association and American Osteopathic Association master files and had to be active, nonfederal, office- or hospital-based practitioners spending at least 20 hours weekly in direct patient care. Residents and fellows were excluded. Questions about information technology were introduced in the 2000-01 round. The 2000-01 survey covered approximately 12,000 physicians; the 2004-05 survey included responses from more than 6,600. Response rates were 59 percent in 2000-01 and 52 percent in 2004-05.

Sources and Further Reading

Barrett, Craig, and Mark McClellan. Draft AHIC Chronic Care Workgroup Recommendation Letter (May 1, 2006).

Gullo, Kelly. "Many Nationwide Believe in the Potential Benefits of Electronic Medical Records and are Interested in Online Communications with Physicians." HarrisInteractive Health Care Poll (March 2005).

Reed, Marie C., and Joy M. Grossman. "Growing Availability of Clinical Information Technology in Physician Practices." Data Bulletin No. 31, Center for Studying Health System Change (June 2006).

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 (September 2004).

Car, Josip, and Aziz Shiekh. "Email Consultations in Health Care: 1 — Scope and Effectiveness, and 2 — Acceptability and Safe Application." BMJ, Vol. 329 (August 2004).

Pew Internet and American Life Project. Data available at: http://www.pewinternet.org/.