The Internet: You’ve Got Mail … Or Do You?

Patients have long expressed a desire for e-mail access to their physicians. So why hasn’t it caught on? Communicating with patients via e-mail is nothing new. But few physicians do it. “It still doesn’t seem to be catching fire by any means,” says Christopher Crow, a family physician in Plano, Texas.

According to a September 2006 study by the Center for Studying Health System Change, only about one in four physicians uses e-mail to communicate with patients about clinical issues. In March 2006, the Journal of Medical Internet Research reported the results of a survey of more than 4,000 primary-care physicians in Florida that found that fewer than 17 percent had ever used e-mail to communicate with their patients and that barely 3 percent e-mailed their patients frequently.

But e-mail usage among the general public has increased dramatically over the past decade - from 9 percent in 1995 to 74 percent in 2005, according to a recent Harris Interactive healthcare poll. So why aren’t more physicians making use of this technology to better serve their patients?

Floodgate fear

Topping the list of concerns that physicians typically cite regarding e-mailing patients is that they will be “swamped” with e-mail correspondence - a daunting task when busy doctors barely have enough time to see their patients, return phone calls, and tend to their practice’s business concerns. Crow theorizes that busy practices may perceive e-mail correspondence with patients as just more work, since they know some people will still prefer telephone contact.

In Crow’s three-physician group, Village Health Partners in Plano, Texas, named Practice of the Year by Physicians Practice in 2006, a couple hundred patients pay $50 annually for unlimited e-mail access to their physicians. On average, those patients e-mail the practice once or twice a year, reports Crow, who dismisses physicians’ fear of e-mail inundation as unfounded.

“Every doctor’s office that I’ve ever talked to that has done this has had the exact same experience,” says Crow. “There are no floodgates [opening]. Because people are too busy and mostly respectful of your time.” Crow and his partners have found that rather than slow them down, giving their patients e-mail access to them helps their practice run more efficiently. “It evens out our workload,” he says.

Sandra Baucom, founding owner of Renaissance Pediatrics in Chesapeake, Va., agrees. “[E-mail] has cut way down on phone tag,” she says. Her practice manager, Laurie Brady, adds, “Providers used to spend at least a half-hour to an hour at the end of their day or miss their lunch making phone calls, and now they don’t have to do that.” Instead, they use breaks between patients or during the occasional no-show to respond to a quick e-mail or two. “E-mails are just so much more convenient than the telephone,” says Baucom. “And people don’t abuse it.”

Is it safe?

Concerns about patient privacy and data security - and running afoul of HIPAA regulations - also keep many physicians from embracing ordinary e-mail communication with their patients. And rightly so, says Eric Soto, chief information officer of iHealthSpot.com, a Florida-based Internet marketing company for physicians.

“The main challenge is that Internet e-mail is horribly insecure, not to mention unreliable,” says Soto. “There’s absolutely no guarantee that if I send you a message it will get to you or … that I really did send you that message.” This is true of free e-mail services like Hotmail and Yahoo as well as e-mail accounts accessed via a company’s network or fee-based Internet service providers, he says. “The bottom line is that e-mail is 30-year-old technology.”

Encryption technology exists, but it can be complicated for the average user. A better solution, say the experts, is to exchange messages with patients using a secure Web site. Crow - whose practice relies on Kryptiq software, which connects with its GE Healthcare Centricity EMR - compares accessing encrypted e-mail to online banking. Patients must use a user name and password and agree to certain conditions before signing up for the service (such as acknowledging that it is for non-urgent queries only). They can then send messages to their physicians via a secure format. Patients are notified by e-mail when their physicians have replied, and they sign back on to the secure Web site to retrieve their messages.

“It’s good practice to use a secure methodology if you’re going to integrate e-mail into your daily activities, because it gives you a greater probability of ensuring that your communication doesn’t have an unintended privacy breach,” says healthcare IT consultant Bruce Kleaveland, president of Kleaveland Consulting in Seattle.

Baucom’s practice communicates with patients via HealthMatics Access, which interfaces with the practice’s integrated EMR and practice management system. A bonus, says Baucom, is that e-mail automatically documents patient interactions: “You push one button that says, ‘Save to the chart.’”

E-mail vs. e-visits

It’s important to distinguish between e-mail that serves to replace phone calls and “e-visits,” which may replace office visits.

While there is no single definition of what constitutes an e-visit, the term generally describes an online patient consultation - as opposed to, say, an e-mailed refill request.

“What I’d define as an e-visit is a fairly structured encounter that’s serving as an alternative to an office visit when appropriate, with an established patient,” says Kleaveland. Few insurers currently reimburse for e-visits. Those that do pay for very structured encounters also frequently require providers to complete detailed forms. Such payers also often require patient copays for e-visits, Kleaveland says. In general, insurers do not pay for e-mails that serve to replace telephone calls.

In Crow’s practice, patients can use e-mail to schedule appointments, request prescription refills, ask generic questions, and access portions of their medical records online. Occasionally, Crow says he receives an e-mail about a problem he’s not able to address electronically, such as a patient reporting a rash. In such cases, he asks the patient to make an office appointment.

Baucom says she uses e-mail to replace phone visits with patients whose conditions require weekly follow-ups - she wasn’t being reimbursed for those encounters anyway. “Now I’m doing those more efficiently over the Internet,” she says. “It’s all about customer service around here.”

In general, secure e-mail Web site services charge a monthly subscription fee. Renaissance Pediatrics paid a one-time startup fee of $1,500 per physician and now pays $75 per physician per month for continuing service. Cost wasn’t an issue, says Brady.

“In my opinion, the bigger barriers are deciding how you’re going to use [e-mail] in the context of your practice,” says Kleaveland. “It should make your practice more efficient and make it easier for your patients to communicate with you.”

Better medicine?

Improving communication with her patients is of utmost concern to Baucom. “Because of the nature of my practice, I have a lot of patients with chronic problems, mental health issues, and other behavioral learning issues,” she explains. National guidelines stipulate that physicians who prescribe psychiatric drugs to children should follow them closely.

E-mail allows Baucom to do this.

Before tapping into e-mail to communicate with her patients, Baucom found it difficult to get them to return to the office for weekly visits. “So I use [e-mail] when I’m starting kids on antidepressants or when I start kids on new ADD medicine. I say to the parents, ‘You need to e-mail me once a week for the next four weeks, and this is what I want to know.’”

Patient satisfaction is certainly a big reason physicians cite for embracing e-mail. A 2005 study in The Journal of the American Board of Family Practice reported that satisfaction among both patients and physicians improved in a group that used e-mail to communicate versus another group that did not. The study concluded that e-mail has the potential to improve the doctor-patient relationship by cultivating better communication.

“We always want to be on the frontier of delivering better service and providing access points for patients to interact with our office,” says Crow.

Baucom believes that physician-patient e-mail communication gives her practice a competitive edge. “We want to practice high-quality medicine, and we want to do anything we can do that’s going to make people go out of here smiling,” she says. It seems to be working: “Patient satisfaction is through the roof.”

Abigail Green is a freelance writer in Baltimore, Md. She can be reached via editor@physicianspractice.com.

This article originally appeared in the April 2007 issue of Physicians Practice.