Patients e-mail -- but they still keep calling

Electronic mail has been touted as a way to improve physician-patient communication. A study finds it can. But that doesn't mean it'll save you time.

By Tyler Chin, amednews staff. June 10, 2002.

After he began exchanging electronic mail with his patients, James Kluzinski, MD, a family physician in Indianapolis, got requests for a refill "for the white pill."

He had, of course, previously told his patients that any refill request made online should include the name of the medication, as well as the pharmacy's phone number.

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Dr. Kluzinski then would have to ask a staff member to pull the chart and/or telephone the patient to confirm or determine just what medication was needed.

"I found e-mails to be time-consuming. They generated an awful lot of calls," Dr. Kluzinski said. So he discontinued e-mail access for patients six months after offering that option.

A study by researchers at the University of Michigan Health System in Ann Arbor appears to confirm that Dr. Kluzinski's experience with physician-patient e-mail isn't an aberration, and suggests that e-mail may not be the efficiency driver that some in the industry believe it can be.

The large, randomized study found that e-mail did not offset the volume of patient phone calls and office visits, said Steven Katz, MD, an internist at the University of Michigan who directed and co-authored the study published in the May American Journal of Managed Care.

The study, conducted over a 10-month period ending in July 2001, split participants -- 98 doctors and about 750 patients at two primary care clinics -- into two groups.

The intervention group used a "triaged" e-mail system under which e-mails from patients were first read and handled by nurses while those in the control group used conventional, uncontrolled e-mail, going straight to the physician.

The study found that patients in the intervention group e-mailed physicians at a rate five times greater than patients in the control group, Dr. Katz said. And yet, despite the difference in the rate of usage, the rate of phone calls and appointment no-shows remained the same for both the intervention and control groups.

Just another chore?

Proponents of online communication say e-mail can save doctors time and money -- reducing phone tag and office visits -- if patients use it to schedule appointments, request refills and ask follow-up questions.

But e-mail, at least initially, is an "add-on" task for physicians because heavy users of e-mail typically are younger, healthier, better-educated people who tend not to call or visit physicians, Dr. Katz said.

By contrast, those who do tend to call or visit are usually older, sicker patients who shy away from e-mailing their doctors.

"If people sign off on the notion that [e-mail] is going to simplify our work environment, then that expectation is not likely to be met initially," Dr. Katz said. That could change later as older, sicker patients grow more comfortable with the technology.

Another major finding from the study is that patients will use e-mail appropriately if physicians set guidelines, then manage expectations by educating patients about when e-mail should be used, what is appropriate content and when they could expect a response, he said.

"That's an important lesson, at least in our setting, primary care, suggesting [that if] you can make this available the right way, patients don't abuse it, they don't overwhelm you with it and their communication is appropriate," he said. "I believe we received only one e-mail that was unrelated to health issues."

Although the study concluded "that e-mail is a potentially attractive way" for patients to communicate, it also suggested that e-mail is "highly limited" because it does not have the robust functionality of the Web, Dr. Katz said. Doctors and patients can do a lot more using Web-based tools to communicate with each other than they can with using just e-mail.

How does it work, really?

Joseph Weiss, MD, a rheumatologist in Livonia, Mich., near where the University of Michigan Health System is located, believes the study isn't true to life because it used a university system. The university system is a referral institution that tends to get a lot of seriously ill patients who tend to be older, its clinics tend to be crowded, and it's hard for patients, who come from all over the state, to visit the clinic, he said.

But Dr. Katz said the study's results were valid. "Our primary care network cares for over 100,000 patients living in southeast Michigan. We have a very mixed patient population with many managed care contracts, Blue Cross, Medicare, Medicaid, etc. This was the site of our study. Our subspecialty clinics do get many referrals from distant locations, but our primary care network serves a very large local community."

Dr. Weiss, who refers patients to the University of Michigan and communicates online with his patients, finds patient-physician e-mail both a burden and a time-saver. He was not a participant in the system's e-mail study.

It's a burden because he checks and responds to e-mail sent by patients only after he has finished everything else he has to do at the office and gone through his stack of regular mail, including letters and medical journals. But that same e-mail also saves him time because the senders aren't calling, he said.

"The patients who talk to me on the telephone are the patients who are most anxious, and they do manage to pack a lot of questions in a little e-mail," Dr. Weiss said. "So I have to spend some time responding to them. The advantage that the e-mail gives me is that I can do it on my own time instead of either having to answer questions during the day and disrupting my day, or having to answer a long number of telephone calls at the end of the day."

Whether e-mail can increase efficiency for physicians will depend in part on the type of practice and how they use the telephone, Dr. Weiss said. For example, his policy is to return calls within an hour.

Dr. Weiss engages in e-mail exchanges with his patients because that's what some of them want. "Whether it's efficient or not is not the issue for me. If [a patient] wants e-mail, I'll do it. I'm in a very competitive market; I'm not about to antagonize people."

Forget about it

Don C. Chaplin, MD, an internist in Burlington, N.C., doesn't exchange e-mail with patients even though he's quite familiar with the technology and checks his e-mail three or four times a day.

When patients do e-mail him, Dr. Chaplin doesn't respond electronically. Instead, he prints the e-mail, asks a nurse to pull a chart and question patients over the phone about symptoms. The nurse then gives him everything he needs to make a decision.

"It's an extra step for me because I have to initiate the process rather than my system initiating the process" with a call, he said.

Dr. Chaplin said one reason why he operates this way is that he is a poor typist. He also worries that patients might e-mail him about urgent medical problems while he is on vacation or otherwise out of the office.

"Neither my office nor I am prepared to interact by e-mail with patients at this time," he said.

ADDITIONAL INFORMATION:

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Highlights of "Bridging the Electronic Divide: Patient and Provider Perspectives on E-mail Communication in Primary Care":

Objective: Determining e-mail utilization patterns, and attitudes of patients and physicians toward e-mail in an outpatient primary care setting; evaluating the impact of e-mail on clinical resources.
Participants: 98 physicians and 750 patients at two primary care clinics.
Methodology: Researchers set up an intervention group of physicians and patients who used a triaged e-mail system and a control group whose patients used conventional, uncontrolled e-mail. Study was conducted over 10 months, including a one-month survey about patients' and physicians' attitudes toward using e-mail.
Conclusion: Patient-physician e-mail may diffuse slowly into the primary care practice setting because of concerns about efficiency, effectiveness and whether e-mail use will improve the relationship between patients and physicians and other health care professionals. Managed care organizations that plan to build e-mail and Web-based patient portals will need to promote these technologies in a way that educates both patients and health care professionals about their appropriate uses.

Source: American Journal of Managed Care, May