The Problem

One issue that affects patients, clinicians, and staff is the health system’s reliance on conventional office visits and phone calls to relay information. In particular, patients are often frustrated in their attempts to get non-urgent advice and information from their clinician or from administrative staff without visiting the practice. First, calling hours are often inconvenient, especially for working patients. Second, when patients do call, they are typically put on hold, only to leave a message and hope they can avoid a game of “phone tag” with the clinician. Finally, unless the patient takes excellent notes, some of the information delivered over the phone may be lost or misunderstood.

The Intervention

One way to facilitate communication is to offer some or all patients the ability to exchange e-mail with their clinicians’ offices. Patients, clinicians, and office staff can use e-mail for multiple purposes:

  • To request and provide information or advice related to non-urgent concerns.
  • To request administrative help (e.g., with forms) and schedule appointments.
  • To request referrals.
  • To communicate results of lab and diagnostic tests.
  • To request and refill prescriptions.
  • To transmit patient-monitored clinical measures, such as blood pressure, glucose levels, or temperature.
  • To provide patient education and other materials, including links to appropriate Web sites.
  • To send reminders.
  • To clarify billing issues.

A recent survey indicates that about 75 percent of adult patients are interested in communicating with their doctors online. When asked whether the use of e-mail by a physician would have an affect on their decisions, 62 percent said that it would influence their choice a great deal or to some extent.[1]

Learn more about what patients want.

"When so many people want something—in this case the ability to communicate online with their physicians—the system (or the marketplace) will eventually provide it. It seems safe to predict that within a fairly short space of time many doctors will be communicating with their patients on the Internet. This will happen because some doctors and health plans will use this as a way to differentiate themselves from their competitors. Some doctors will embrace this as an opportunity to grow their practices. Some health plans will require, or incent, physicians to be accessible online. It is only a question of how quickly this will happen." [2]

Benefits of This Intervention

E-mail communication offers several benefits. It is convenient, fast, asynchronous (i.e., both people do not have to be available at the same time), unintrusive (i.e., it does not interrupt the recipient on either end), and easy to track and manage, unlike telephone messages. Because it facilitates communications between patients and their doctors, e-mail has the potential to improve patient-centered care and increase self-management, while increasing timeliness and efficiency. Another possible benefit is improved adherence to treatment and medication, and a general increase in patient involvement in their own care. [3] A recent study has also found cost savings associated with the use of online communications.[4]

Another advantage of e-mail is that it provides a written record of what transpired and what information was conveyed to the clinician and patient; copies of this documentation can be incorporated into the patient’s medical record.[5] However, the ability to integrate e-mail into the medical record raises issues of informed consent and the adequacy of safeguards to protect privacy and confidentiality.[6]

Implementation of This Intervention

A number of organizations offer guidelines regarding the use of e-mail in health care settings. Key sources include:

The guidelines cover e-mail content, informed consent, turnaround time, acknowledgements of receipt, documentation and record keeping, appropriateness of tone, and limitations (e.g., concerns about discussing sensitive subjects). Perhaps the biggest consideration in these guidelines is the security of personal health information and the liability risks associated with e-mail communications, particularly in light of the HIPAA regulations. (HIPAA refers to the Health Insurance Portability and Accountability Act of 1996.) HIPAA requires that health care organizations take steps to safeguard patient confidentiality by:

  • ensuring that messages cannot be tampered with (by authenticating the contents),
  • implementing the security standards for Protected Health Information (possibly through encryption), and
  • maintaining records that can be audited.

Review a sample of the guideline recommendations.

Because of the security issues, there are basically two approaches you can consider if you decide to implement e-mail communications. One option is to use existing e-mail capabilities. This requires that the medical practice or clinic become familiar with the implications of HIPAA and implement various systems and measures to manage the flow of information (e.g., systems to forward the e-mails when a clinician is out of the office for a few days) and to minimize risk. However, while it is possible to comply with many aspects of the current guidelines for physician-patient electronic communications, you would not be able to offer a secure network through a standard e-mail system.

A second, albeit more costly, option is to use the services of a secure messaging vendor; current examples include RelayHealth.com, MyDocOnline.com, and HealthyEmail.org. These vendors offer off-the-shelf products that medical groups can use to send and receive information in a secure Internet-based environment. Typically, these products enable communications that are more structured and presumably more efficient than regular e-mail would be, in that patients are submitting forms and templates rather than free-flow text.

Constraints on Use of This Intervention

Because electronic communication – whether through standard e-mail or secure networks – is fairly familiar to most patients and clinicians, this intervention does not face some of the technical and logistical obstacles typical of information system strategies. Some clinicians resist due to concerns about the privacy of electronic communications (particularly through standard e-mail systems), while others worry about the potential volume of messages they could be asked to handle.

However, the lack of compensation to clinicians for their time poses the most substantial barrier. In a survey of doctors, over half of those who were not using e-mail and who indicated a preference for “face-to-face” pointed to insurance reimbursement as the most important factor that would compel them to use e-mail. [7] (For an interesting perspective on these common concerns, see: Sands DZ. Using E-mail in Clinical Care: A Practical Approach Combining the Best of High-tech and High Touch.

A small number of health plans are paying doctors to do online consultations. For example, after a pilot program demonstrated improvements in patient satisfaction and health care savings of $3.69 per member per month, several health plans agreed to reimburse physicians for online consults. However, it is not common for physicians to be reimbursed for the time they spend responding to e-mails (nor are they typically compensated for time on the phone).

Some of the secure messaging vendors are working with providers on this issue; in addition, some products incorporate ways to obtain payments directly from patients, especially for online consultations. In the Harris Interactive survey of patients with Internet access, over a third indicated a willingness to pay for online access to their clinicians.[8] Some health care organizations charge patients for access to e-mail services; Portland-based GreenField Health, for instance, was charging an annual fee of $350 to each patient who wanted to participate in the service.[9]

Example

Several health plans and medical groups have begun to use e-mail to facilitate communications between patients and clinicians. At Washington-based Group Health Cooperative (GHC), for example, about 20,000 of 300,000 eligible patients have signed up for an online service called MyGroupHealth (www.ghc.org). Using the plan’s Internet portal, patients can communicate over a secure network with their personal health care teams, refill medications, and schedule appointments. The site also gives them access to searchable health information as well as discussion groups. (Learn more about Internet Access for Health Information and Advice and Support Groups and Self-Care.) In a survey of these online users, GHC found that 92 percent would recommend the service to others, and that 58% say they stay at GHC because of the online services.[10]

Other examples include:

  • PatientSite at Beth Israel Deaconess Medical Center and Caregroup HealthCare System, Boston, Massachusetts: https://www.patientsite.org/default.asp
    PatientSite is a secure personalized messaging system that allows patients to communicate with their health care provider via the Internet. It is designed to facilitate discussion of questions about treatment that may arise between visits.[11]
  • My Health Online at Palo Alto Medical Foundation, Palo Alto, California: http://www.pamf.org
    Patients who enroll in My Health Online can communicate through a secure network with their doctors and advice nurses.

Key Resources

[1] Wall Street Journal Online/Harris Interactive Health-Care Poll. Few Patients Use or Have Access to Online Services for Communicating with their Doctors, but Most Would Like To. Available at: http://www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=1096. Accessed May 5, 2008.
[2] Harris Interactive Patient/Physician Online Communication: Many patients want it, would pay for it, and it would influence their choice of doctors and health plans. Health Care News 2002;2(8). Available at: http://www.harrisinteractive.com/news/newsletters/healthnews/HI_HealthCareNews2002Vol2_Iss08.pdf. Accessed March 5, 2008.
[3] Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: problems and promise. Ann Intern Med 1998;129(6): 495-500.
[4] Relay Health Corporation. The RelayHealth Web Visit Study: Final Report 2002-2003. Available at: http://www.relayhealth.com/rh/GENERAL/studyResults/webVisitStudyResults.pdf. Accessed April 28, 2008.
[5] Kane B and Sands DZ. Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. J Am Med Inform Assoc 1998;5(1): 104-11.
[6] Bauchner H, Adams W, Burstin H. “You’ve got mail”: issues in communicating with patients and their families by e-mail. Pediatrics 2002;109(5): 954-6.
[7] Fulcrum Analytics and Deloitte Research. Taking the Pulse v 2.0: Physicians and Emerging Information Technologies. New York; 2002.
[8] Harris Interactive Patient/Physician Online Communication: Many patients want it, would pay for it, and it would influence their choice of doctors and health plans. Health Care News 2002;2(8). Available at: http://www.harrisinteractive.com/news/newsletters/healthnews/HI_HealthCareNews2002Vol2_Iss08.pdf. Accessed March 5, 2008.
[9] iHealthBeat. Oregon clinic streamlines office with e-mail service 27 May 2003.Available at: http://www.ihealthbeat.org.Accessed March 5, 2008.
[10] Eytan T. Personal communication with Ted Eytan, MD, MS, MPH . Physician Lead, MyGroupHealth, Group Health Cooperative — Health Informatics Division, March 18, 2003.
[11] Learn more at:. Weingart SN, Rind D, Tofias Z, Sands DZ. Who Uses the Patient Internet Portal? The PatientSite Experience. J Am Med Inform Assoc. 2006;13:91–95.