An e-mail system that triages messages from patients to their doctors can help overcome many of the concerns that doctors have about electronic communication, and increase the amount and quality of communication between providers and patients. But it doesn't cut the number of phone calls or office visits patients make, nor the number who miss their appointments.
These results, from the first large randomized, controlled study of e-mail communication between physicians and patients, will be presented on May 4 by researchers from the University of Michigan Health System at the annual meeting of the Society for General Internal Medicine.
The e-mail study was funded by Intel Corporation and performed by members of the UMHS Consortium for Health Outcomes, Innovation, and Cost Effectiveness Studies (CHOICES). Among other findings, it showed that the messages from patients that got through the system to the doctors were appropriate ones that the doctors needed to see or answer, such as patients' updates on their condition, questions about their health, and prescription and referral requests.
Now, the same researchers have expanded their study to the World Wide Web, through grants from Intel and the U-M Medical School to develop and implement a web portal developed by UMHS, Intel and McKesson Information Solutions. Final results from that study aren't yet available, but already 1,300 patients of 130 U-M physicians have registered, and the system has received 1,600 messages to schedule appointments, renew prescriptions, request referrals, read health information tailored to their needs, and ask health questions.
"Medicine has lagged behind the rest of the world in using e-mail and the web to communicate important, time-sensitive information and conduct transactions, but the concerns that have held us back seem to decrease when we provide a framework for this kind of interaction," says Steven Katz, M.D., MPH, director of the study and an associate professor of internal medicine and health management & policy at the U-M.
Adds co-investigator David Stern, M.D., Ph.D., an assistant professor of internal medicine, "We hope our studies will help guide the evolution of the kind of electronic communication and access that many of our patients and peers tell us they want. Further research is needed on other issues and concerns, but this is a good first step toward establishing a model for Internet-based physician-patient links."
Surveys by UMHS researchers and others have found that the public and physicians want to communicate with one another by e-mail and the web, but concerns about cost, time, convenience and privacy have slowed the use of these new technologies in health care. The UMHS team will publish more of their findings in this area in a paper in the May issue of the American Journal of Managed Care.
The UMHS e-mail study being presented at SGIM pitted conventional, uncontrolled e-mail against a system in which patients were asked to send e-mails to a single e-mail address where they could be sorted and triaged by clinic staff and nurses, then sent to the patient's physician if appropriate. The system is called the Electronic Messaging and Information Link, or EMAIL.
The researchers randomized 98 UMHS primary-care physicians and residents in two clinics to either the EMAIL system or the conventional system. The patients of the 50 doctors randomized to the EMAIL system received information on how the system worked and encouragement to use it. Those patients whose doctors were randomized to no intervention could still connect with their doctor through the usual ways -- mostly phone and office visits, but occasionally by e-mail.
The study recorded how many patient e-mails, calls and appointment no-shows occurred among both groups over a nine-month period. The researchers also surveyed all the study physicians and a random sample of their patients, to assess attitudes toward electronic patient-provider communication and satisfaction with care. With patients' consent, they also analyzed the content of patient messages that the EMAIL system sent to physicians.
In all, patients in the EMAIL system group sent messages to their doctors at up to five times the rate of patients in the control group, reaching 49 messages per 100 scheduled visits midway through the study.
"But the sharp increase in e-mails didn't mean a corresponding drop in calls and no-shows," with rates of both remaining about the same for both groups, Katz notes. "This was because the group of patients who used e-mail were not the same group who frequently call or visit their doctor. Rather, e-mailers appeared to be new communicators taking advantage of a new way to reach their doctor." This issue of increased physician work-load from patient contact via e-mail, and specifically how to allow time and bill for it, has been a major concern for many physicians.
Another chief concern among those resisting the routine use of e-mail between doctors and patients has been the issue of appropriateness -- the fear that patients will send messages to their physicians that are irrelevant, frequent, complex, or could be handled by others.
The EMAIL triage system used in the study was designed to allay that fear. It passed all patient e-mails through nurses and other staff first, allowing them to process requests and questions like those they would normally handle if they came in through the clinic's phone triage system. Patients were asked to keep their e-mails focused on one question or piece of information.
The largest percentage of these messages -- 27 percent -- turned out to be from patients who wanted to provide their physicians with an update on their condition or events like emergency room visits or medication side effects, says researcher Casey White, Assistant Dean for Medical Education at the U-M Medical School.
White analyzed the content of a random sample of 359 of the 1,629 messages received by the EMAIL account. "This kind of use highlights the need to ensure that electronic communication between patients and providers is appropriately documented in medical records," she added.
White and her colleagues also found that 18 percent of the messages were about prescriptions, 10 percent asked the physician to refer the patient to a service or specialist, and 5 percent asked for the results of laboratory tests. Only 9 percent asked the physician a health question. Importantly, just a few messages were judged inappropriate, irrelevant or too complicated for physicians and staff to handle.
After the study ended, the researchers surveyed physicians and a sample of patients in both groups to assess their attitudes toward physician-patient e-mail and other types of communication. More than 90 percent of physicians and 62 percent of the patients responded. Patients and especially physicians who took part in the EMAIL system were much more likely than those in the control group to see e-mail as a good way to communicate. There was no difference between the study groups in general satisfaction with clinical care.
Physicians in the EMAIL group were much less likely to see patient e-mail as bothersome. And their patients were much less likely to feel that e-mail raised barriers in the communications process with their health care provider.
In all, the researchers say, the study's results show that a the right e-mail system can improve provider and patient attitudes toward this new way of communicating, but that it does increase the work-load in the clinic. Says Katz, "Patients are hungry for easier ways to navigate the complexity of the medical system, and electronic patient-provider communication offers a new way to improve care. However, our results suggest that e-mail may be a limited option. We think the World Wide Web is the better way to go because it is more secure, offers patients many more services, and is much easier for clinic staff to use. This is why we are moving quickly beyond regular e-mail, and into evaluating web-based tools that patients can use to communicate with their doctors and clinic staff."