Physician-Patient E-Mail: Why Aren't We Using a 'Low-Tech' Tool To Boost Quality?

by Nir Menachemi


Like many Americans, I take advantage of the conveniences that the Internet makes possible. This past month, for example, after filing my taxes electronically, I booked an airline ticket online, completed the teaching of an online course, purchased several items online and reserved a table at a local restaurant online. Despite these conveniences, I, like most Americans, do not have the regular option of communicating with my physician online -- which could potentially save me, my health insurer and my physician time and/or money. Incidentally, recent data suggest that I am in the majority of Americans who are interested in being able to e-mail their doctor.

Most physicians do not e-mail with their patients, and this situation is not surprising. Policymakers and health care leaders interested in improving our health care system have focused more attention on using health IT for boosting effectiveness (e.g. evidence-based decision support) and efficiency (e.g. reducing redundant tests, improving use of existing data through health information exchange) rather than for issues pertaining to patient centeredness (i.e. things patients want). We have spent comparatively little time thinking about ways to make physician-patient e-mails a common occurrence in our health care system.

The HITECH Act and current meaningful use requirements do not directly address e-mail use between patients and providers. As a result, most physicians have no incentives (financial or otherwise) to begin using e-mail with their patients, especially given the perception that e-mailing patients would create additional work with no additional reimbursements.

Research on Physician-Patient E-Mail

My colleagues and I have studied the use of e-mail between physicians and patients for several years. One concerning trend we have found in our research is that physicians who use e-mail with patients frequently fail to use best-practice guidelines developed by the American Medical Informatics Association and the American Medical Association that are designed to protect privacy and liability concerns for both physicians and patients. In fact, we have found that over the past several years, physician interest in using e-mail with patients has decreased, and so has their adoption of these best practice guidelines.

Specifically, our research examined e-mail use among physicians in Florida in 2005 and then again in 2008. Overall, we collected data from more than 6,000 physicians and examined:

  1. Whether e-mail use with patients has changed over time; and
  2. Whether physicians have more readily embraced the best-practice guidelines since 2005 when use of these guidelines was relatively low. 

We found that compared with 2005, physicians in 2008 were more likely to have ever used e-mail with patients in their practice (13% versus 16.6%). However, the percentage of physicians in both years that frequently used e-mail with their patients remained steady at 2.9%.

In 2008, the percentage of physicians who expressed a future interest in using e-mail to communicate with patients was more than 10% lower than in the 2005 study.

Of the 2.9% of physicians that frequently e-mailed with patients, adherence rates to the 13 individual best-practice recommendations were all lower in 2008 than in 2005. Adherence rates were significantly lower for four of the recommendations, including:

  • "Print e-mail communication and place it in patients' charts" (only 39% did so in 2008, compared with 48% in 2005);
  • "Inform patients about privacy issues with respect to e-mail" (only 29% did so in 2008, compared with 36.3% in 2005);
  • "When e-mail message becomes too lengthy, notify patients to come in to discuss or call them" (only 16% did so in 2008, compared with 22% in 2005); and
  • "Send a new message to inform patients of completion of request" (only 11% did so in 2008, compared with 16% in 2005).

Why and How To Boost Use of Physician-Patient E-Mail

Previous research has shown that e-mail communication between physicians and patients can improve patient convenience, satisfaction and access to care. Additionally, when used appropriately, e-mail communication potentially can cut back on unnecessary visits that burden the primary care system.

Importantly, the primary care system is expected to be further taxed with demands stemming from health reform. Thus, health care leaders need to consider ways to promote or incentivize this underutilized technology in the clinical setting. Some potential first steps might include:

  • Quantifying potential averted costs (e.g. eliminated unnecessary visits, reduced call volume) from the use of physician-patient e-mail and more regularly financially incentivizing physicians to provide this service when appropriate;
  • Training nursing and other office staff to assist in responding to routine messages that are not flagged as confidential;
  • Educating patients on the "do's and don'ts" of e-mailing with their physician; and
  • Encouraging physicians to adopt best-practice guidelines and determining ways to implement these guidelines more easily into workflows.

With the changes expected from the HITECH Act and the health reform law, patient demand for an increasingly wired and convenient health care system will continue to grow. We currently have an opportunity to get ahead of the curve.

patrick freeman
Patients, tech-saavy under age 60 who cannot directly e-mail their doctors will (and should) begin to abandon their doctor in favor of physicians who DO e-mail. The 'financial incentive' to force doctors to use e-mail is that they will (and should) LOSE patients/clients if they do not.
Daniel Sands
Interestingly, when I co-authored the first paper regarding best practices for patient-provider electronic communication for the American Medical Informatics Association published in 1998 -- 13 years ago! -- I naively assumed that everyone would start using e-mail in their practices. Sadly, we've made little progress in adopting this very simple patient-centric tool (made even more powerful because the technology is now embedded into patient portals that integrate with EHRs).

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