E-mail means fewer patient calls and visits

Despite concerns that online consults are not usually reimbursed, e-mail advocates say the technology offers greater practice flexibility, time efficiencies and marketing power.

By Pamela Lewis Dolan — Posted Aug. 27, 2007

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A Kaiser Permanente study showing that physicians who e-mailed with patients saw a drop in visits raises the specter that online communication might reduce revenue.

But doctors who were early adopters in e-mailing patients -- and who didn't participate in the study -- say that even though such communication might keep some patients out of the office, it opens up more space for patients who might have a more pressing need to come in. And they say patient e-mail reduces the amount of time they spend on the telephone with patients -- which Kaiser's study also found to be true.

Jasmine Moghissi, MD, a family physician in solo practice in Fairfax, Va., has been e-mailing patients for several years. She said that although it hasn't reduced the amount of work in the office, it's made the same amount of work easier to handle.

"It's like taking a phone call at your leisure. I almost never talk to patients on the phone. I find when I do, it's like an office visit, it's like 20 minutes," she said. "I will do the e-mail with them because I can control how much time I spend on it, and I can control when."

Researchers studied 4,686 patients from the Kaiser Permanente Northwest region who use the medical group's KP HealthConnect system, which gives secure e-mail access to doctors. Members had used HealthConnect for at least 13 months and had used at least one feature. The group was compared with a control group of 3,201 members, matched by age, sex and conditions, who did not use HealthConnect.

Annual office visits for registered HealthConnect users decreased by 10.3% during the study, conducted between September 2002 and August 2005. The corresponding decrease in office visits for the control group was 3.7%. HealthConnect users also phoned their physicians 13.7% less than did the control group.

The study's authors, whose work was published in the July American Journal of Managed Care, said the reduced visits didn't negatively impact Kaiser's doctors financially because they work in a capitated environment, where physicians are reimbursed on a per-member, per-month basis no matter how much a patient seeks medical care. But "in noncapitated systems, an overall reduction in office visit rates may not be financially advantageous," the study said.

Some physicians have been reluctant to start e-mailing due to the unwillingness of insurers and patients to pay for it. Some insurers do pay doctors for e-mail consultations, but it's an idea that has been slow to catch on. Most insurer projects are still in the pilot stage or have rolled out to a limited number of physicians.

"Health plans paying for a piece of this has been almost meaningless," said Edward Fotsch, MD. Fotsch is the CEO of Medem, which offers iHealthrecord, an online communication and personal health record system for doctors and patients.

Medem, whose owners include the AMA and other medical societies, allows patients to e-mail doctors' offices free of charge. But to e-mail a doctor directly, a patient has to enter a credit card number and is charged for an e-consultation. There are about 10,000 doctors using the system. Dr. Fotsch said the charge for e-consults is typically the same as a co-pay, which makes the insurer's involvement in the process unnecessary.

"In our view ... if you want your doctor's professional time and he uses his professional time to make a living, it is not unreasonable to pay him for his time," Dr. Fotsch said.

But e-mailing advocates say physicians shouldn't fear a downturn in income from online consultations.

David Levey, MD, an internist at the Montefiore Medical Group's Riverdale location in Bronx, N.Y., says that even if his four-physician office gave the option to charge for e-mailing, he likely wouldn't. He said the efficiencies and the marketing power he has gained by having e-mail outweigh the costs of providing it.

Dr. Moghissi said e-mailing has become a marketing tool for her. It helped her retain patients when she decided to go solo. Many patients followed her, she said, simply because she vowed to continue e-mailing.

Dr. Moghissi also has found e-mailing to be more accurate than her former system of giving a message to the receptionist, who then calls the patient and relays the message back to Dr. Moghissi.

Numerous studies have shown what appears to be a pent-up demand by patients for online consultations. A Harris Interactive poll conducted in 2006 found that 74% of patients would like to use e-mail to communicate directly with their physicians, but only 8% of the survey respondents had access to that service.

But opening up the e-mail channel doesn't necessarily mean a physician will be deluged by requests and messages. Kaiser study co-author Yi Yvonne Zhou, PhD, said physicians thought they would be overwhelmed by the volume of e-mails and that patients would abuse it. They were surprised to find that wasn't the case. Each doctor averaged about two messages per day, Dr. Zhou said.

AMA policy supports the use of e-mail, and it recommends that physicians set guidelines for such use, which include an established turnaround time for responses. The policy also states that physicians can eliminate e-mail privileges for patients who do not follow the established guidelines or who abuse the system.

Dr. Moghissi said she occasionally gets long "annoying" e-mails, but that overall it's a positive thing. She learned through trial and error how to deal with each type of e-mail. For example, she saves the long e-mails for later in the day and has told patients the longer the e-mail, the longer it takes for a response.

One of the surprising things Kaiser co-author Terhilda Garrido, MPH, said she learned through the research was that it's not just the young, tech-savvy generation who is demanding the convenience of e-mail.

The majority of HealthConnect users are older, Garrido said. Many of the older patients have chronic conditions and are the patients who would be more likely to have questions for their doctors.

Dr. Moghissi considers the e-mail service to be the new phone call. "You don't get reimbursed for it, but you didn't get reimbursed for phone calls either," she said. "It's cheaper than a phone call and easier to document."

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Demand outpacing supply

A Wall Street Journal Online/Harris Interactive Poll found doctors are lagging in Internet-based communications. And 62% of patients said the ability to talk to a physician electronically would affect their choice of doctors.

What patients want Want Have and use Have but don't use
Reminders via e-mail 77% 4% 3%
Online scheduling 75% 3% 4%
E-mail directly with doctor 74% 4% 4%
Test results via e-mail 67% 2% 3%
Electronic medical record 64% 2% 3%
Home monitoring device 57% 2% 3%

Note: This survey of 2,624 U.S. adults, released in September 2006, was conducted online between Sept. 5 and Sept. 7. There was a sampling error of 3 percentage points.

Source: Wall Street Journal Online/Harris Interactive

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Some have mail

The percentage of physicians using e-mail is low, but slowly increasing, according to a survey by Manhattan Research.

2005 24%
2006 25%
2007 31%

Note: Survey results are based on telephone surveys of 1,353 physicians in the first quarter of this year.

Source: Manhattan Research

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Privacy a problem for patient e-mails

Even though, by its nature, e-mail is an informal way of communicating with patients, experts say doctors must not overlook privacy-protecting protocols.

Many large medical centers use encrypted services that patients must log into with a password to send messages. But Jasmine Moghissi, MD, a family doctor in Fairfax, Va., says this would be too cumbersome for many of her patients and would deter them from trying to communicate electronically.

Safety precautions can be taken with a nonencrypted system, said practice consultant Dona Sandefur, who is on assignment as chief operating officer of the Queens-Long Island Medical Group for Pivot Healthcare. But she hasn't seen one yet that likely would pass muster with HIPAA attorneys.

The big concern, she said, is the possibility of e-mail landing in the inbox of someone other than the patient for whom it's intended.

Because of that concern, Dr. Moghissi said, she never uses names in the text of an e-mail, and when sending test results, the e-mail never specifies the type of test.

Additionally, each patient who wants to e-mail must sign a release form agreeing to receive e-mails from the nonencrypted system. Dr. Moghissi said she also encourages patients not to use their work e-mail addresses for communications about their health care.

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