Patient email satisfaction starts with managed expectations

As more patient-physician communication moves to Web-based messaging systems, patients have the ability to contact their doctors at any time, day or night. So now physicians face the question of whether they need to assign call duty to the practice's electronic mail system.

Surveys have found that a large majority of patients are interested in online communication with their physicians. But other studies have found that patient satisfaction rates could take a significant dive if the messages aren't responded to in an appropriate period of time. Researchers at Mayo Clinic found that although family physicians generally respond to messages during the week in a timely fashion, the weekends are a different matter.

For a report in the April-June issue of Quality Management in Health Care, Mayo Clinic researchers analyzed 323 messages randomly selected from 7,322 collected for the study. They found that nearly all messages sent Monday through Friday were opened within 12 hours. But on the weekend, 87.1% of messages weren't opened in at least 36 hours.

“In a way, this shouldn't have surprised us,” said James Rohrer, PhD, professor of family medicine at Mayo Clinic and co-author of the study. “But the fact is, most people don't work on the weekends. The clinicians are not there, and these things pile up in their in-boxes, and no one is responding.”

There is no evidence that negative consequences or outcomes are associated with longer delays, Rohrer said. But researchers want to study further whether there should be a standard for how responses should be sent, and how delays in response times affect patient satisfaction and health care decision-making.

Other surveys have found a correlation between patient satisfaction and message response times. A 2003 survey of patients using an online messaging service at the University of California, Davis, Medical Centers' primary care network found that all patients who received a response right away were “very satisfied.” The rate of those who were “very satisfied” dropped to 73.8% when a response didn't come until the next day. The more the response time increased, the more satisfaction decreased.

Some experts say managing patient satisfaction goes hand in hand with managing their expectations. Others say how quickly a physician responds may be determined by the design of the messaging system they are using or the way the practice handles messages.

Let patients know when you'll respond

Montefiore Medical Center in New York has never examined response times for messages, but it has conducted two patient satisfaction studies since it launched a secure email messaging system in 2008. Both surveys found very high satisfaction rates even though many messages weren't answered for two days, said Michael Dowling, PhD, chief administrative officer at CMO, the Montefiore Care Management company of Montefiore Medical Center.

When patients sign up for the secure messaging service, they agree to terms of use that include an expectation that messages could take up to two business days to be answered, Dowling said. When patients send messages, “they are not expecting the clock to start ticking until the next day,” he said.

Kaiser Permanente helps set expectations by reminding patients as they go through the process of sending a message that the service is not intended for urgent questions and that a response will take one or two business days, said Mark Groshek, MD, a pediatrician and interim medical director for Kaiser's Internet Services Group. He said the patient will be taken through a series of screens to determine whether their matter should be handled by email or whether they need to see or speak to someone more quickly.

Transfer email to an answering service

Telephone calls made to a physician practice after business hours are handled by an answering service. In a similar way, a possible solution presented in Mayo Clinic's study was to reroute electronic messages to a call center.

This solution would require the person answering the message to have access to important information about the patient so that the message is passed to the right person. Feedback also would be required, so that the primary care physician will know how the situation was handled.

Another option would be to give patients a choice. They could send the message to an on-call person or a primary care physician with an understanding that there will be a delay in response.

Dr. Groshek said that when physicians are off duty or on vacation from Kaiser, their colleagues can check messages for them. The messaging system is part of the electronic health record system and shows when new messages have arrived. The colleagues have the option of replying themselves or telling the patient the physician is not available.

He said physicians have the option of checking messages while outside of the office, but they are not expected to do so. “There are a lot of physicians who find it's not that hard to do, in which case they may end up responding. But we respect people's days off and expect them to take them for their own sanity, as well.”