American College of Physicians: Internal Medicine — Doctors for Adults ®


Physicians and e-mail slow to make connection

While some embrace the online visit, others view it as more uncompensated work

From the January-February ACP Observer, copyright © 2007 by the American College of Physicians.

By Bonnie Darves

Like many young physicians, Beverly Hills, Calif. internist Alex Foxman, ACP Member, grew up using e-mail. So when he opened his solo practice in Beverly Hills three-and-a-half years ago, he naturally incorporated e-mail into his practice. Today, it's not uncommon for Dr. Foxman to respond to a patient's e-mail inquiry about lab results while he's out of the office or to pick up a cell phone text message from a patient with a medication question.

"I started using [patient] e-mail as an experiment, but it's been so efficient that I plan to expand it," said Dr. Foxman. "It truly enables me to practice medicine from outside my office." The GE Centricity physician office software that he uses allows him to access patient records remotely and address non-urgent matters via e-mail. That's a service his patients appreciate.

"A lot of my patients are professional people on the go, and this makes it more convenient for them to access me," he said, when issues arise regarding lab test results or appointment follow-up matters. "I have found that it's easier for me to send an e-mail message than to have the receptionist call back or risk playing voice-mail tag."

If the extent to which e-mail has become a part of Americans' daily personal and professional lives were any measure of what's going on in medical practice, physician-patient e-mail communication would have skyrocketed by now. But practices like Dr. Foxman's are still rare.

Although doctors and patients are e-communicating more now than they did a few years ago, the uptick has been modest. The Center for Studying Health System Change (HSC) Community Tracking Study Physician Survey found that in 2005, 24% of physicians reported their practice used e-mail to communicate clinical issues with patients. That's up only slightly, from 20% in 2001.

The nationally representative survey of more than 6,600 physicians also found that e-mail use increased at a faster clip in small practices than in large ones over that period, said study co-author Joy Grossman, Ph.D., a senior researcher at the Washington, D.C., organization. While 20% of physicians in practices with nine or fewer physicians reported physician-patient e-mail, only 29% of those in practices with 50 or more physicians did so. Practices with nine or fewer doctors reported an increase from 16% to 20% between 2001 and 2005. Physicians in practices with 50 or more doctors reported increasing from 27% to only 29% over the same period.

"My sense from talking to physicians throughout the state is that the two main issues are lack of reimbursement and fear of litigation," said Robert G. Brooks, FACP, who recently co-authored a survey of 15,000 Florida physicians published in March 2006 in the Journal of Medical Internet Research. Only 16.6% of respondents reported having ever used e-mail with patients and only 2.9% reported using it frequently to communicate with patients, noted Dr. Brooks, associate dean for health affairs at the Florida State University School of Medicine in Tallahassee.

Practical and logistical concerns have also kept many physicians from embracing the trend, said Dr. Grossman. "Many would like to see some evidence (of) whether e-mail will make their lives easier and deliver a clear clinical bang for the buck," she said. "Physicians already have so many modes of communication they must deal with, and they may be concerned that adding another one might make their lives more complicated."

More work, less pay?

Small practices, in particular, are concerned that e-mail represents more uncompensated work for the physician. A recent survey by the College's Center for Practice Innovation found that only 18% of 131 small practices surveyed reported using e-mail with patients for clinical advice, diagnosis or treatment communications, according to Michael Barr, FACP, vice president of practice advocacy and improvement. And 80% reported no use at all for such purposes.

Reimbursement of physician-patient e-mail or e-visits is moving forward slowly. About 20 U.S. health plans and insurers have initiated pilot programs or rolled out payment schemes, with average payments ranging from $25 to $35, according to the consulting firm PricewaterhouseCoopers. Many of those plans are using RelayHealth, which offers highly structured clinical e-visits for members of about 15 health plans and also handles patient copayments and claims filing for physicians.

The American Medical Association in 2004 established a CPT code, 0074T, for online medical evaluations between doctors and patients who have an existing relationship. Insurers that recognize the CPT code, and reimbursement for associated claims require that the e-exchange produce a documentable action. That might include a medication change, ordering of a diagnostic test or a specialist referral.

The reimbursement issue is far more complicated than determining whether a particular e-mail exchange is "billable," according to Charles Kilo, FACP, a fellow of the Institute for Healthcare Improvement and a longtime proponent of medical practice performance improvement. "Payers are starting to pay for e-care, but the question becomes … how much they pay and whether that payment ends up being worth it to the practice," said Dr. Kilo, founder and CEO of GreenField Health in Portland, Ore. If the reimbursement rate is $30, but the practice must go through hoops to collect a $10 copayment from the patient after the e-mail "transaction" has concluded, for example, the hassle factor could outweigh the financial gain.

Early adopters aren't inundated

Many internists who have taken the leap into the patient e-mail realm have been encouraged by the results and patients' respect of their time.

Dr. Foxman now receives an average of 250 patient messages per month, and the volume is increasing at a rate of 10 to 30 per month. Even at that level, he said he is neither inundated nor overwhelmed, concerns many internists cite when deciding whether to add e-mail. "Most people really are not interested in talking to their doctor every day," Dr. Foxman said.

Similarly, general internist Bill J. Johnson, ACP Member, of Grapevine, Texas, who began using e-mail with patients more than three years ago, said he has never been deluged with messages despite having his e-mail address posted on the practice's Web site.

"In our market, people understand the proper nature of e-mail—that they can send me a message when they want, and I can respond when I'm available," he said. "I rarely receive truly urgent e-mails or messages." There's also a sort of implicit understanding, Dr. Johnson said, that a 24- to 48-hour response turnaround is acceptable. Staff members at the practice, Prevention First, also post their e-mail addresses, and patients tend to direct their messages to the front desk scheduler or nurse when they're seeking an appointment or a prescription refill, for example.

If patients overuse e-mail in an obvious attempt to avoid coming in, or for an issue that's too complex for that venue, Dr. Johnson becomes less responsive or lets the patient know that the problem necessitates a visit. "If I find I'm writing more than three or four sentences, I say 'This is a little complex to explain over e-mail,'" and he urges the patient to schedule an appointment.

Drs. Foxman and Johnson have refrained from charging for e-mail access, and both use internal programs rather than hosted ones or structured platforms offered by technology vendors. Despite the free service, neither has experienced much abusive use. "A few patients have used e-mail to try to avoid a [visit] co-pay, but I can count them on one hand," Dr. Johnson said.

Even GreenField Health, which has used patient e-mail and e-visits since its inception in 2001 and charges a monthly practice membership fee, has experienced neither inundation nor abuse despite the fact that 75% of its 2,500 patients communicate via mail.

"Generally that doesn't happen," said Dr. Kilo. "By and large people are phenomenally respectful of our time." A handful of patients do abuse the e-visits and the e-mail access, but resolving the issue is usually just a matter of "having a talk with them," Dr. Kilo explained.

Arvind Cavale, ACP Member, a solo-practicing endocrinologist in Southampton, Pa., has used e-mail to communicate with his patients for more than two years. An estimated 20% of his 6,000 patients, primarily those with diabetes or other chronic illness, have happily signed on. He uses e-mail only with established patients who have regular follow-up appointments on the calendar, but otherwise sets no ground rules.

"A few people have taken advantage of our kindness—canceling appointments or trying to only use e-mail," he conceded. "But when that happens we just tell them they need to come in."

Efficiency, cost impact

Ellen Burkett, ACP Member, one of two internists at Southpark Internal Medicine and medical director of MedSouth IPA, in Highland Ranch, Colo., said patient e-mail usage has reduced phone time for both her and her staff. "It certainly reduces the voice-mail tag when patients are trying to make appointments," she said.

Dr. Burkett, who uses the online service ReachMyDoctor (RMD; see sidebar), said e-mail definitely can help reduce expenses as more patients elect to use it. Because patients can link to their lab results via RMD, Dr. Burkett foresees a time when she'll no longer have to mail a letter to a patient every time a test result comes in, which her practice does regardless of the test findings.

"We'd like to jettison that [function], because we're spending $1,200 to $1,800 on mail, and e-mail is basically free," she said. "Some physicians think it will add work, but these are the same patients who call their office with the same questions. [With e-mail], you also have a record of it [the exchange]."

Data being collected by large national organizations such as Kaiser Permanente may soon shed light on e-mail's effect on clinical practice. Since implementing "e-mail your doctor" functionality last year, Kaiser Permanente's Northwest region has reported that phone calls to physician offices decreased by 14% and appointments by 7%.

"We have 50 to 100 times the message volume of any other service, so we hope to be able to mine that data soon," said Edward Cohen, FACP, who led the implementation of the e-mail program, part of the KP HealthConnect electronic medical information system, in Northern California last November. He acknowledged that Kaiser Permanente's primary care physicians—about 2,300 of the 6,000 physicians in that region—were concerned about the potential for extra workload."

"There's no question that there was a fair amount of trepidation, especially about the message volume," Dr. Cohen said. "Some doctors think the only thing that stands between them and an avalanche of work is the 'friction' in the system." In fact, although Kaiser Permanente hasn't conducted a formal content analysis, between 80% and 90% of messages reviewed "have been appropriate," he said, and readily answered.

For Dr. Cavale, e-mail usage enables his practice to more readily handle the large volume of data uploading—of glucose levels, for example—that would be extremely cumbersome if obtained through other means. That data upload accounts for two-thirds of the e-mail usage, with the remaining third associated with appointment issues or non-urgent health issues. Dr. Cavale also suspects that e-mail use has reduced phone calls. "I do know that the e-mail becomes a second line of communication when phone lines are jammed," he said, based on the flurry of messages received during such times.

For Eugene, Ore., family physician Christa Danielson, MD, interviewed for an ACP Observer article in 2004 when she first began using e-mail, initial concerns about message content or volume have proved unfounded. "I rarely receive rambling e-mails, and I would say that it [adding e-mail] has been pretty work neutral," she said. "I truly believe that it gets people off the phone, and I know that it has increased the appeal of the practice."

Will it improve care?

Intuitively, it might seem that e-mail would improve quality, if only by virtue of the fact that patients can either inquire about something they forgot to bring up in a visit—or access and inquire about test results. And physicians who use e-mail are seeing both. But to date, there is scant data.

Even if there aren't data on outcomes improvements, said Dr. Kilo, quality improvements are evident. "From the patient's perspective, if quality is about relationships and the opportunity to communicate with us on their time," he said, "there are huge gains."

That patient push for more communication avenues is borne out by the early experience of Kaiser Permanente. By October 2006, Kaiser Permanente had 1.9 million registered users nationwide and had tallied 1,079,681 patient-initiated e-mail messages to providers.

"The fascinating question is: does it [e-mail] change clinical outcomes?" Dr. Cohen said. "I don't think there's enough in the literature to say one way or the other. The hope is that this is an easier channel for people to get to their clinicians—so if preventive care really works, this should help."

Dr. Cavale noted that e-mail fosters closer connections and collaboration between patient and doctors. "I certainly have gotten to know my patients better," he said. "But more important, it has enabled us to convert diabetes management into continuous management, not episodic care. We want to prove to the payers as well as the medical community that Diabetes management is a 'continuous process' and should be compensated as such. E-mail communications saved directly into electronic patient records can serve as excellent documentation/proof of medical care."

For his part, however, Dr. Cavale isn't holding his breath waiting for local insurers to pay for the time he spends using e-mail to manage his patients, which in the case of patients with chronic conditions might total a half-dozen e-mail exchanges between visits.

"Making the insurance companies believe that this actually works to improve outcomes and is worth paying for is the hard part," Dr. Cavale said, "even though those six e-mails could easily have been converted into two extra office visits."

Bonnie Darves is a free-lance writer in Lake Oswego, Ore.


Tips for patient e-mail usage

Internists who are considering using e-mail or are just starting out might benefit from the following basic tips from veteran users:

Start small. Rather than opening up the entire practice at once, considering starting with a few dozen patients who have either expressed an interest in e-mail or are likely e-mail users.

Use a disclaimer and set the ground rules via an agreement. Ironically, many practices that don't use structured platforms or hosted services have not set the "rules of engagement" through an informed-consent agreement that patients sign. That's important, experts contend, so that both parties know what's acceptable and expected.

That agreement should detail not only whether the exchange is secure or "non-secure" but also what's deemed appropriate content, the patient's responsibility and expected response times. At the very least, patients should be advised on what's acceptable "content" for e-mail exchanges, what the privacy risks are, and especially, that the format should not be used for urgent or emergent medical problems.

Consider using a subscription service. Ellen Burkett, ACP Member, a Highlands Ranch, Colo., general internist, uses ReachMyDoctor (RMD), for which patients pay a monthly subscription of $8.95 to gain secure e-mail access to their physicians. Doctors who participate in the program receive approximately 80% of the revenues collected, a proposition that has proved viable to Dr. Burkett, who has approximately 50 patients on RMD. The companies Kryptiq and Medem, among others, also offer secure messaging services.

Keep a record. One of the potential benefits of e-mail is that it documents exchanges between physicians and patients, so either include a copy of messages in the patient chart or paste them into electronic health records.

Avoid sarcasm, irony or "joking" in e-mail. These can come back to haunt even careful physicians who have established relationships with their patients, should anything go wrong.

"Sign off" on each message. It's advisable to append a standard text block to each message that includes the internist's full name, contact details and information about security (or the lack) of the information exchanges.

For more extensive guidance, see guidelines published by the American Medical Association in June 2002 and the American Medical Informatics Association.

The ERisk Guidelines, published in 2005 and available online, provide a concise overview of patient e-mail security and privacy considerations.


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