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, according to a recent study.
But it doesn’t cut the number of phone calls or office visits patients make, or the number who miss their appointments.
These results, from the first large randomized, controlled study of e-mail communication between physicians and patients, were presented recently by researchers from the Ann Arbor-based University of Michigan Health System (UMHS) at the annual meeting of the Society for General Internal Medicine. The e-mail study was funded by Intel Corp. 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, says Steven Katz, MD, MPH, director of the study and an associate professor of internal medicine and health management & policy at UM.
"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," Katz says.
David Stern, MD, PhD, an assistant professor of internal medicine, a fellow researcher in the study, says the results should reassure physicians and risk managers who are reluctant to use e-mail for communicating with patients.
"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," Stern says. "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 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 E-MAIL.
The researchers randomized 98 UMHS primary care physicians and residents in two clinics to either the E-MAIL system or the conventional system. The patients of the 50 doctors randomized to the E-MAIL 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 between 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 E-MAIL system sent to physicians.
In all, patients in the E-MAIL 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.
A 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 E-MAIL 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% — turned out to be from patients who wanted to provide their physicians with an update on their condition or events such as emergency room visits or medication side effects, says researcher Casey White, assistant dean for medical education at UM Medical School. White analyzed the content of a random sample of 359 of the 1,629 messages received by the E-MAIL account. "This kind of use highlights the need to ensure that electronic communication between patients and providers is appropriately documented in medical records."
White and her colleagues also found that 18% of the messages were about prescriptions, 10% asked the physician to refer the patient to a service or specialist, and 5% asked for the results of laboratory tests. Only 9% asked the physician a health question. Importantly, just a few messages were judged inappropriate, irrelevant, or too complicated for physicians and staff to handle.
Patients and especially physicians who took part in the E-MAIL 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.
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