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AAOS Now

Published 11/1/2013
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Mary Ann Porucznik

Can You Read Me Now?

Patients like email, but physicians see it as a challenge

The popularity and widespread use of electronic communications cannot be debated. In fact, the phenomenal growth of social media such as Facebook and Twitter has almost surpassed the significance of email.

But not when it comes to medicine. Electronic communications between patients and physicians are still rare, and with good reason, according to a recent study in the journal Health Affairs. Although surveys agree that most patients are interested in online communication with their physicians, the opposite isn’t necessarily true, even within healthcare systems that encourage the use of electronic communications.

According to lead author Tara F. Bishop, MD, MPH, assistant professor in the departments of public health and medicine at Weill Cornell Medical College in New York City, “Leaders of medical groups that use electronic communication find it to be efficient and effective. But many physicians say that, while it may help patients, it’s a challenge for them.”

Dr. Bishop and colleagues interviewed the leaders of 21 medical groups that widely use electronic communication with patients. They also talked with staff in six of those groups. They wanted to know how electronic communications could be used to manage clinical issues that are traditionally handled during office visits. The interviews also covered the perceived disadvantages of electronic communication for patients, physicians, and practices, as well as barriers or facilitators to the use of electronic communications.

5 to 50 emails daily
All the groups used electronic communications to facilitate care in the following areas:

  • to communicate test results
  • to allow patients to request medication refills
  • to allow patients to make appointments
  • to allow patients to ask questions of their physicians

Three of the groups used nurses, medical assistants, or case managers to triage messages from patients. In the other three groups, patients could not only contact the office for appointments and email a nurse with a medication refill request, they could also email their physician directly. Physicians received between 5 and 50 emails a day.

Only one of the groups charged patients for “e-visits”—email that involved clinical decision making. This group—an academic health service located in a Midwestern state—had negotiated reimbursements for e-visits (typically less than for in-person visits) with some private insurers. However, no charges were assessed for other forms of electronic communications.

Time to respond to electronic communications was handled in different ways by the various groups. Two groups added “desktop medicine time” to their providers’ schedules, which reduced the number of patients seen by providers during the day, while a third group allowed providers to decide how many patients to see each day so that they could balance face-to-face and electronic communications. At the other three groups, staff reviewed the clinical schedule in advance to determine whether a scheduled visit could be handled by phone or electronically, then contacted and offered that option to the patient.

Thumbs up, thumbs down
Of the 21 groups contacted, 14 gave electronic communications a “thumbs up” for convenience and 18 responded that patients were more satisfied after the program opened. Efficiency was also cited as an advantage, because responding to emails typically takes only a few minutes.

But the impact on physicians was typically not as satisfying as it was for patients. Although electronic communications did seem to reduce office visits for individual patients, many physicians did not see a reduction in overall workload. “Their clinics send them additional patients to see,” noted Dr. Bishop.

Physicians also expressed the feeling that their work was never done. “Each email takes little time, but the emails add up,” said one. “In one day, I’ve been in touch with 60 of my patients—10 in person and 50 through email.” The study quotes another physician as saying, “There’s no end to it. This has allowed us to work all the time.”

And responding to emails on a timely basis is important. Another survey found that 100 percent of patients who received an immediate response were “very satisfied.” If the response didn’t come until the next day, the percentage of those who were “very satisfied” dropped to 73.8 percent. And the longer it took to receive a response, the more the rate fell.

Researchers noted that the payment model was a motivator for shifting face-to-face visits to electronic communication. “Face-to-face visits generate revenue for groups being paid fee-for-service,” they wrote. But in groups that used a capitated model, under which they received a set amount for each patient, regardless of the services provided to that patient, electronic communication was more popular.

Researchers also found that insurance companies were reluctant to pay for e-visits. According to one health leader interviewed, “The health plans say, ‘The physicians are already doing it for free; why would we pay for it?’”

Compensation will remain a stumbling block, said Dr. Bishop. “Until different payment models emerge, electronic communication is unlikely to be widely adopted by physician practices.”

The study was funded by a grant from the Commonwealth Fund.

Dr. Bishop’s coauthors for “Electronic Communication Improves Access, But Barriers To Its Widespread Adoption Remain” (Health Affairs, August 2013) include Matthew J. Press, MD, MSc; Jayme L. Mendelsohn, MPH; and Lawrence P. Casalino, MD, MPH, PhD. No disclosure information on the authors was available.

Bottom Line

  • Electronic communication between patients and providers is both efficient and effective, improving patient satisfaction and saving patient time.
  • Providers, however, find that communicating with patients electronically is extra—and often uncompensated—work that makes them feel that “their day can never end.”
  • Although responding to email may not take much time, patient satisfaction may depend more on how rapidly that response is provided.

Additional Information

  1. AMA Code of Medical Ethics on The Use of Electronic Mail
  2. AMA Guidelines for Patient-Physician Electronic Mail
  3. Bishop TF, Press MJ, Mendelsohn JL, Casalino LP: Electronic communication improves access, but barriers to its widespread adoption remain. Health Aff (Millwood) 2013;32(8):1361–1367.
  4. Rohrer JE, North F, Angstman KB, Oberhelman SS, Meunier MR: Timely response to secure messages from primary care patients. Qual Manag Health Care. 2013;22(2):161-166. doi: 10.1097/QMH.0b013e31828be314.