Email Communication With Patients Is Not Common…Yet

In a report released earlier this month (October 2010), the Center for Studying Health System Change (HSC) reported survey results that, “physician adoption and use of e-mail with patients remains uncommon—only 6.7 percent of office-based physicians routinely e-mailed patients in 2008…” This low rate of email utilization occurred despite the availability of the technology in 33% of the office-based physicians surveyed.

The barriers documented were fairly typical: lack of reimbursement, concern about privacy & security, worries about additional work, and fear of increased malpractice liability or a negative impact on clinical care.  However, physicians in practices with EHRs, “…were more than twice as likely to report having access to e-mail and were more than three times as likely to use it routinely to communicate with patients when available, compared with physicians in practices using paper records exclusively.” Are physicians with EHRs less risk averse, willing to take on more work without additional reimbursement, or not concerned about clinical care? Such a difference in character is unlikely.  The authors of the HSC report (Ellyn Boukus, Joy Grossman, and Ann O’Malley) speculate a few possible explanations including that, “having an EMR may support more efficient and effective e-mail use and documentation in the patient’s medical record than using e-mail tools on a stand-alone basis with paper charts.”

Clearly there are important workflow and patient care considerations when initiating email communication with patients/families. Some practices start with administrative issues (e.g., appointment requests/changes, billing concerns, routine prescription refills) before considering true clinical exchanges via email.  Using email to siphon off non-emergent administrative issues from the telephone call volume can allow administrative staff to be more efficient by managing email requests between peak busy times in the office.

With respect to clinical issues, the AMA has a set of guidelines about Physician-Patient Electronic Communications and the American Medical Informatics Association (AMIA) published guidelines about use of email in 1998 that while just a bit outdated, include some very good advice about setting parameters for this type of communication.

According to a California Health Care Foundation survey, 67% of patients looked for information about a disease or medical problem online (page 5 of survey) and 69% of people surveyed without a personal health record indicated that they are either somewhat interested or very interested in sending or receiving email from a doctor or nurse (page 10 of survey).  It’s just a matter of time before this becomes an expectation.

So…are you using secure, HIPAA-compliant email in your office? If so, how’s it going?  If you’re not, why – and under what circumstances would you consider introducing email communication with patients?

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.


2 responses to "Email Communication With Patients Is Not Common…Yet"
  • October 31, 2010
    Richard Lamson, MD

    The hard part is the “HIPAA-compliant” adjective. Email per se is not going to be HIPAA-compliant because it is not secure as is. If you want to send material to the patient (or vice versa), you need to do one of two things:
    1. Strong encryption: because the medium itself is not secure, the data must be encrypted before transmission. The infrastructure for doing this is almost there, but the patient and physician need to exchange encryption keys. The email needs to be encrypted twice, once with the physician’s private key and once with the patient’s public key; that way the patient knows that only she or he can read it, and also knows that it was “signed” by the physician. The physician can publish a public key (the decryption key for the private key) in a public place, e.g., a practice web site. However, there is not yet a mechanism for average users to publish their public keys.
    2. A secure web site. You can probably make a case for sending an unencrypted email that says that there is something to pick up on the secure communications site. The patient would have to verify their access (perhaps they would be given passwords in the physician’s office) and then log in to obtain their messages. The email would only contain a nondescript message (“please pick up your secure message at http://…”). They could send replies there as well. This is significantly less convenient than the former method, but already works.
    Of course, the latter method also works as a physician portal, if the patient wants to look up lab work results, etc. I’m not absolutely convinced we want every user to see every lab result (I can see panicked calls from patients wanting an explanation for the elevation in their RDWs, for example, or what I consider a normal value might be marked as abnormal by the lab; e.g., most labs say 102 is abnormally high HDL, while for most patients it’s acceptable).

  • June 20, 2011
    Margene Birtcher

    Hi, I like your blog.

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