Doctor-Patient Email: A Revolution Waiting to Happen

Christine Wiebe


March 28, 2003


When Steven Katz, MD, began researching how email would revolutionize doctor-patient communications, colleagues warned him the transformation would be complete before he could ever finish a study. Today, however, he realizes that the general population isn't nearly as keen on communicating with their doctor electronically as early enthusiasts expected.

"We have this revolution going on outside the medical milieu," he said, but it hasn't yet swept the realm of healthcare. Personally, he still is passionate about the potential for doctors and patients to link electronically, but his studies have failed to document its worth.

"It does give pause to the exuberance of this," he admitted.

The rapid growth in email gave leaders hope that electronic messaging would spread to healthcare as well. However, problems with standard programs, such as the popular America Online, quickly became apparent, such as lax security and lack of control over the types of messages that doctors would receive. That led to the development of secure messaging systems, which are Web-based applications that are more secure and provide structured questions that guide patients in their queries.

Electronic messaging is available to a growing number of patients across the country, but the phenomenon has spread slowly. Only recently has the pace picked up, with almost daily announcements of new messaging systems being tested or launched. A recent study that found such systems could reduce medical costs may spur even wider adoption.

In the meantime, however, most patients still interact with doctors the old-fashioned way -- face-to-face or over the phone. Doctors usually are blamed for slowing the spread of electronic communication systems, just as they resisted taking phone calls from patients for many years. Ironically, however, researchers now recognize that many patients are equally reticent about turning on their computer to contact their doctor.

"People who are comfortable using an Internet browser to do other things online really like it," said Michael Good, MD, a family physician in Middleton, Connecticut, who offers Web-based messaging. "But most of us have been surprised by what a small percentage of the population that is."

Although some patients are enthusiastic about the service, most have never tried it and some were frustrated when they did. "There's a whole skill set that a lot of people don't have," Dr. Good said. Even those who regularly use email for personal matters may not know how to navigate or interact on a Web site, he said.

"It's very hard for people who use the Internet a lot to remember that a lot of people don't and can't," he said. "There's a real cultural divide."

That realization was a big "Oh!" for him, he said, laughing. When his practice introduced electronic messaging, he thought the change would be dramatic. "It's not as grand as I originally dreamed."

Despite the slow rate of acceptance, advocates of online messaging still are convinced of its value in healthcare. In a recent study, researchers analyzed insurance claims and found that costs were reduced more than $3 per patient per month for those with online access to their doctor compared with those in a control group.

"I was surprised by the fact that we got savings at all," said Laurence Baker, Associate Professor of Health Research and Policy at Stanford University, Stanford, California, who coauthored the study.

The pilot project was designed to reimburse doctors for responding to patients' electronic messages; patients paid $5 to $10 for each contact. Several large self-insured employers in California, along with insurers Blue Shield of California and ConnectiCare, participated in the project and provided claims data. The online messaging service was provided by RelayHealth, an Internet communications provider previously known as Healinx. On the RelayHealth Web site, patients log in to send a formatted message to their doctor, who can reply at a convenient time.

Both patients and physicians who used the service rated it highly, both for convenience and for quality. However, the study did not address the issue of the larger population of patients and physicians who chose not to use the service.

Baker's overall conclusion: "There are people who like this, and there is evidence that it can save money."

That's enough to sell some companies on the idea, said Eric Zimmerman, Senior Vice President for Marketing at RelayHealth.

"As a result of the study, health plans are starting to embrace this," he said. Several large insurers that were waiting on the sidelines now are moving to adopt the service, he added.

Provider acceptance also has increased significantly since the idea first was introduced, Zimmerman said. Many doctors were worried the online service would open the floodgates for frivolous messages from patients and would introduce new liability threats. However, the Web-based service is more secure than email and is structured to focus patient queries and to limit free-form communications, he said.

Several other services are available on the Web for patients to communicate with doctors, and some large healthcare systems have developed their own internal Web-based systems.

In December, a consortium of medical societies and malpractice insurers called the eRisk Working Group for Healthcare unveiled uniform guidelines designed to limit the liability risk of electronic doctor-patient communications. Standards include a mandate that such messages only occur within the context of a preexisting relationship, and that they be provided only through secure networks rather than via standard email.

The main barrier for doctors, however, has been a reluctance to offer a new service without getting paid. Now that more insurers are willing to reimburse doctors for the service, that attitude may change.

"I feel a lot better about taking some time to give people advice when they pay you for it," admitted family physician Dr. Good. Last year, he earned about $1000 for fielding patients' online messages. That may not seem like much, he said, but it's better than nothing, which is what he gets for answering patients' questions by phone.

"As physicians, we have this problem that we are drowning in phone calls, and we have to find a better way to deal with these things," Dr. Good said. Online messaging "replaces something that is a time-consuming money loser into a less time-consuming source of income," he said.

Most of the messages he receives are about simple matters, such as renewing a prescription or scheduling a laboratory test. Only a few patients have contacted him about more complex diagnostic matters, he said. His office staff prints out messages every 2 hours or so and attaches them to the patient's record for him to review throughout the day.

Those messages, written in a patient's own words, generally are more clear than those phoned in and filtered through the office receptionist, Dr. Good said. He believes the security of those messages is at least as good as that of paper records, and the malpractice exposure is no greater than with undocumented phone calls.

So far, about 1000 of his group's 12,000 patients have taken advantage of the online service, Dr. Good said.

The fact that only a fraction of patients actually use online messaging when it's available is surprising, given that national surveys indicate the public is clamoring for the chance. A 2002 Harris Poll found that 70% of patients said they wanted online access to their doctors, and nearly 40% were willing to pay for the service. Yet, when offered the opportunity, a much smaller proportion ends up using it.

"There's an irony here," said researcher Dr. Katz. "If you build it they will come," he said, "but they don't bust the door down."

Patients are not as concerned about privacy as some analysts had predicted, he said. They mostly are uncertain about how the messaging process will work. Some patients simply forget to use the service because they need a doctor so infrequently.

Until patients become more active with electronic messaging programs, insurers will have little incentive to offer or promote such services, said Deb Hoyt, spokesperson for ConnectiCare. Although the HMO will continue to reimburse network doctors who participated in the RelayHealth pilot, she said, "It's no good if nobody uses it."

Despite the cost savings reported in the study, her company has always viewed the service as a "value-added" option rather than a cost cutter. "If there were pennies saved here or there, then that was an added bonus," she said.

More research is needed to determine the true potential for reducing overall health costs, experts agree. But online messaging may offer more immediate benefits for the very doctors who have been reluctant to adopt it.

Office staff in physician practices that participated in the RelayHealth pilot reported that electronic messages about administrative issues were resolved twice as quickly as those handled in person or by phone, said Marcy Kravet, director of e-business for ProHealth Physicians, a large Connecticut group.

Doctors increasingly are looking for ways to reduce the amount of staff time and lost revenue associated with patient phone calls. Some doctors across the country have introduced annual administrative fees for patients, or have begun charging for phone calls. In that context, online consulting may become more popular.

"The future of free phone calls is probably limited," said family physician Dr. Good. "I think that 10 years from now, people will have a choice of fee-for-service phone consultations or fee-for-service email," he said.

Meanwhile, advocates may need to lower their expectations for the future of online messaging.

"We've got to let these systems mature," said researcher Dr. Katz. "We also need to accept that some (patients) will come first, and some will come later, and some will be left behind," he concluded.