In e-communications, walk before you run
E-mail triage gives way to web-based program
A study of an e-mail triage system between clinic physicians and their patients has yielded mixed results, but despite finding a web-based system superior, the director of the study is convinced that such baby steps must precede a full-blown move to Internet communications.
"You don’t change behavior in a day," explains Steven Katz, MD, MPH, associate professor in the departments of Medicine and Health Management and Policy at the University of Michigan in Ann Arbor.
One of the reasons for "walking before running," Katz says, is that culture varies tremendously across clinical groups. "Operations is about changing behavior group by group. You have to understand where people are coming from and go there," he explains. "People who start from the top and say Thou shalt web’ will lose.’
The e-mail study
Katz and his team were invited by Intel to submit a project that would address electronic communication in clinical care.
"At that time, I was receiving e-mail from patients that was difficult to deal with," he recalls. "One patient, in particular, had serious medical problems that really warranted face-to-face visits. I felt that if docs could get these kind requests in an informal structure, they may have problems, and I was interested in tools for communication between patients and providers that worked for both."
The study involved two University of Michigan-affiliated clinics over a 10-month period. Patients were encouraged through mailed brochures and cards to use the new triage-based e-mail system.
All patient e-mails were automatically routed to a central account managed by a "navigator," who passed the messages to appropriate staff. Patients would receive automatic responses containing "dos" and "don’ts" of e-mail communication, clinic phone numbers, and expected response time.
Queries could range from patient updates on their conditions to requests for medication refills. The responses would come from a nurse, scheduling staff, referral clerk, or physician, depending on need. The physicians were "cc’d," but they were not required to respond unless they wanted to; they were nonetheless kept in the loop.
"This had enormous potential," Katz notes. "But there was no business model. Docs are not reimbursed for this, and they wonder how they can fit it into their work lives in a way that will allow them to meet all their other patient needs. They’re also concerned about the appropriateness of communications and how they are used by patients; they don’t want to be put on joke lists or directed to pornography sites."
There also were concerns from the patients’ perspective, Katz point out. "In earlier surveys, they expressed worries about e-mail not getting the job done, that it was not as effective as a phone call, and wondered if the responses and requests would be met promptly or be lost in an abyss of e-mail.
"We found if you build a site in a way that addresses some of these issues, patients and physicians feel better about it, particularly if patients use it properly, send appropriate requests, and don’t abuse it," he says.
At the end of the study period, physicians and patients had indeed warmed up to it, but "it didn’t change their basic perspectives," he concedes.
On to the web
This is what ultimately led Katz into web-based communications between patients and physicians. This approach, Katz says, offers several advantages over e-mail:
- Patients can be given a much more robust interface to work from — more information about schedules, refills, guidelines about requests, and information search capabilities.
- It is much more secure, with user names and passwords protecting privacy.
- Staff prefer the more structured way in which they receive information.
- Documentation is much easier.
Katz says the web is superior in terms of user satisfaction, resource use, and clinical outcomes.
"We can use the web to improve things such as screening for cancer; we can motivate patients to get screened, thus improving quality of care," he says. "This is a watershed moment where people like me can provide information to patients about improving their health."
What the University of Michigan system has done can be replicated in any hospital or system, Katz says.
"Anybody who can use [Microsoft] Outlook or one of the other popular packages can easily build the e-mail system we did," he says. "The web connection can be built, but the problem is operations. You want your web system connected to your data systems, and the cost is nontrivial — not the cost of getting the web in but the cost of changing behavior and getting connected to the system."
What’s more, he adds, when you build it, "they" don’t all come. "We speculate that 15% of the target patient population who could have hit our web site did," he says. "Earlier users tend to be less sick and better educated, but I would argue that’s a good group to start with."
In conclusion, Katz reasserts that human beings are the most important component of this type of system, and the complex composition of a patient base demands a gradual rollout.
"This whole area is one part technology and nine parts people," he says. "We always need to think of our patients’ needs. That calls for rock-solid technology that’s simple to use, rolled out in a phased way.
"Don’t forget, the average patient has a ninth- or 10th-grade education. Whatever you develop must be transaction-rich, with a lot of diverse patient needs easily met by an asynchronous tool known as the web. In the long run, it will also decrease the burden of our providers and staff," Katz concludes.
Key Points
- Since cultures vary across clinical groups, customization is a must.
- Addressing concerns of physicians and patients makes e-mail more palatable.
- Web site offers greater privacy, improves documentation process.
Need More Information?
For more information, contact:
• Steven J. Katz, MD, MPH, Associate Professor, Departments of Medicine and Health Manage-ment and Policy, University of Michigan, Univer-sity of Michigan Health System, 300 N. Ingalls, Suite 7E12; Box 0429, Ann Arbor, MI 48109-0429. Telephone: (734) 936-4787. Fax: (734) 936-8944. E-mail: [email protected].
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