The New World of Physician–Patient Electronic Communication

By Jennifer Larson, contributor

April 1, 2011 - “Take two aspirin and e-mail me in the morning.” Does this sound familiar, yet different? It may be time for this new twist on an old expression.

For years, the only way for patients to contact their doctors remotely was to pick up the telephone and dial the office number. But today a growing number of patients e-mail their doctors directly or use secure Internet portals to communicate with them, causing ongoing discussions about the pros and cons of this new avenue of communication.

The American Medical Association’s official Guidelines for Physician-Patient Electronic Communications maintain that physician–patient e-mail communication can have a number of benefits: physicians can use e-mail to follow up with patients, clarify advice, provide detailed written instructions and include additional educational materials.

And a 2010 study in Health Affairs found that using e-mail to communicate with patients may improve the quality of care that physicians provide. The Kaiser Permanente researchers found that the patients who had e-mail access to their physicians experienced improved control measures for diabetes and hypertension.

New Jersey-based infertility specialist Serena Chen, M.D., finds that e-mail is a very efficient medium for communicating with her patients in certain circumstances. She gives out her e-mail address so she doesn’t have to engage in lengthy rounds of phone tag with patients.

“It really seems to cut down on a lot of that back and forth,” said Chen. “It’s not a substitute for sitting down for a follow-up, but a lot of times people have simple little things that are really bothering them.”

Will it catch on?

The overall number of doctors who communicate with their patients by e-mail is still relatively small.

A 2010 study from the Center for Studying Health System Change (HSC) found that only about 7 percent of doctors routinely used e-mail for communicating about clinical issues in 2008. Doctors that practiced in settings that utilized electronic medical records (EMRs) were more likely to use e-mail, as were doctors who worked in medical school practices, large groups and group/staff-model HMOs.

Concerns typically cited by physicians reluctant to embrace electronic communication with patients include the effect on patient care, security and reimbursement issues. For example, Texas oncologist Kevin Doner, M.D., said he’s concerned about adequate security for messages containing private medical information, as well as whether it’s possible to ensure that the actual patient is the person communicating with him over e-mail.

But many experts agree that more, not less, electronic communication is on the horizon for patient care providers.

“It’s coming,” said Michael Crocetti, M.D., a pediatrician at the Johns Hopkins Bayview Medical Center in Baltimore, Md.. “I don’t think there’s any way around it. We’re either out in front of it…or someone is going to tell us how to do it.”

Crocetti was the co-investigator of a recent study that surveyed 229 parents of children who were patients at the Hopkins Children’s Center. Almost 90 percent of the parents said they would like to be able to communicate with their children’s pediatrician by e-mail, although only 11 percent actually did. But the desire was there.

However, a recent study in the Journal of Medical Internet Research suggests that some doctors are growing less interested in communicating with patients by e-mail.

As explained in “The Use of Physician–Patient E-mail: A Follow-up Examination of Adoption and Best-Practice Adherence 2005-2008,” the authors examined more than 6,000 responses from physicians practicing in Florida and found that e-mail usage did not change significantly between 2005 and 2008.

“More troubling is the decrease in adherence to best practices designed to protect physicians and patients when using e-mail,” the authors wrote. “Policy makers wanting to harness the potential benefits of physician–patient e-mail should devise plans to encourage adherence to best practices.”

Limits of e-mail

Kenny Handelman, M.D., a child and adolescent psychiatrist who practices in a hospital-based clinic in Oakville, Ontario, Canada, believes that e-mail is too limiting to let him provide the best patient care.

“Important details may be missing, and most importantly, it is hard to read emotions through e-mail,” Handelman said. “One cannot read body language or hear the tonality in people’s e-mails.”

He added, “People may want the convenience of e-mail, (but) they need the accuracy of my assessments--which I generally achieve via face to face communication.”

The AMA’s guidelines explain that e-mail should never be used to replace the “crucial interpersonal contacts that are the very basis of the patient–physician relationship.”

“Rather, electronic mail and other forms of Internet communication should be used to enhance such contacts,” the guidelines state.

Plastic surgeon Thomas Fiala, M.D., does communicate with some patients by e-mail for certain reasons, such as arranging an appointment or to view preliminary photos. But at some point, he has to actually see the patient to give a full consultation for an upcoming procedure or to check a surgical site.

“A lot of what we do really involves a physical exam,” said Fiala, who practices in Altamont Springs, Fla.

Appropriate usage

As usage increases, it’s important that physicians and health care organizations are clear about appropriate use of e-mail or other forms of electronic communication. Patients need to understand that they shouldn’t try to e-mail their physicians about acute or emergent symptoms that need to be addressed quickly.

The Henry Ford Health System in Michigan uses an electronic communication system that allows patients and doctors to have consultations called “eVisits.” Using a secure system, patients can submit questions to their physicians. But the system has a disclaimer that instructs patients not to use the electronic system for emergencies, and it also notifies them that they may not receive an answer for 24 hours.

Hilda Ferrar-Blair, M.D., a family medicine physician with Henry Ford, explained that the template allows her to categorize a consultation as “appropriate” or “inappropriate.” Essentially, that allows patients to submit questions or concerns without having to come in for a visit, but she can advise them to come in for a meeting when she deems it necessary.

Crocetti doesn’t have formal guidelines for e-mail usages, but he said that he does advise parents to be succinct. And he lets them know that he’ll respond to them as soon as he can, but it might be the end of the day.

“And there are occasions I’ll tell them, ‘This can’t be handled over e-mail. You’ll have to come in for a visit,’” he said.

Will reimbursement turn the tide?

If their security and reimbursement issues are addressed, it is possible that more physicians will get on board.

“While EMRs may support the adoption of e-mail--and findings from the 2008 Health Tracking Physician Survey suggest that the two are indeed related--this is not a guaranteed outcome,” wrote the HSC study authors. “Moreover, the question remains whether physicians will actually use e-mail in the absence of additional reimbursement for the extra costs required to communicate with patients via e-mail to better coordinate patient care.

A survey from Manhattan Research that was reported by the American Medical Association found that almost 40 percent of U.S. physicians communicated with patients online in 2009. However, most didn’t involve financial compensation. The Healthcare Financial Management Association noted that most physicians don’t practice in an environment that’s set up for reimbursement.

But more entities are finding that it may be worthwhile to establish reimbursement for electronic consultations. One of Henry Ford Health System’s subsidiaries pays doctors $20 for an eVisit, and HFMA found that Cigna pays $25 and Aetna $30, if the participating physician subscribes to the service for a fee.


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