SummaryA pediatric subspecialist offered the families of his patients the opportunity to contact him via e-mail, with formal guidelines established with respect to the appropriate use of the system (e.g., content, length, response time). More than 90 percent of those families offered the service enrolled, with approximately 40 percent using the service during a 2-year period. Families using the service reported enhanced communication with and access to the pediatrician. The physician found that use of the e-mail service saved him time versus answering the same inquiries via the telephone. In addition, over time, the program has engaged more teenagers to contact the doctor directly using electronic communication.Moderate: The evidence consists of evaluation of the use of the e-mail system along with surveys evaluating patient/family satisfaction with the system.
Developing OrganizationsChildren's Hospital of Pittsburgh, Department of Pediatrics, Division of Rheumatology
Date First Implemented2004
Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Children; Age > Infant (1-23 months); Newborn (0-1 month); Preschooler (2-5 years)
Problem AddressedMany patients and their families have nonurgent questions for, or other reasons for wanting to communicate with, their physicians outside of regular office visits. Having these questions addressed typically requires a phone call to the physician's office during normal office hours. This telephone-based approach creates a number of potential problems, including the following:
E-mail communication has the potential to address many of these problems, allowing patients and family members to clearly explain their questions and concerns, in writing, directly to physicians whenever they would like and allowing physicians to respond whenever they have a chance (from the office or from home). E-mail also gives patients and family members access to that response at any time. Surveys show that the vast majority (90 percent) of patients would like to be able to e-mail their physicians, and a sizable minority (37 percent in one study, 42 percent in another) of these individuals are willing to pay for that service.1,2
- Patients and family members may have difficulty reaching someone at the physician's office due to busy telephone signals, automated telephone navigation systems, and/or the failure of office staff to answer the phone in a timely manner.
- Patients may have questions or issues that they would like to raise during nonoffice hours but have no way of communicating that message at that time.
- Patients and family members may find it difficult to explain their questions or concerns clearly to office staff who answer the phone.
- There may be delays in the receipt of telephone messages by the nurse and/or physician who needs to handle the question or concern.
- Even clearly explained questions or concerns may not be appropriately "translated" when the message is relayed to the physician.
- Physicians may find it difficult to find the time to return phone calls during acceptable phoning hours.
- Physicians may return calls at a time when the patient or family member is not home, thus creating the potential for missed calls and/or "telephone tag."
Description of the Innovative ActivityA pediatric subspecialist working in an academic medical center offered his patients the option of communicating with him via e-mail (in addition to being able to access him via other methods, including in-office appointments and the telephone). The patient/family-pediatrician e-mail program works as follows:
- Making patients aware of the e-mail option: All patients and their families who came in for regularly scheduled appointments and new patients were made aware of the option to contact the physician via e-mail and were offered the chance to review and sign the consent form (see below). Using this approach, the vast majority of the pediatrician's patients learned about the program over a period of several months.
- Obtaining informed consent: Patients and family members who were interested in the service were given an informed consent form to sign. This form explained the following guidelines for use of the e-mail system:
- E-mail was not to be used in emergency or other time-sensitive situations.
- E-mail communications should be concise.
- When appropriate, e-mails from patients or family members may be forwarded to other members of the health care team involved in the child's care.
- Any e-mail correspondence becomes a formal part of the child's medical chart.
- E-mails will be responded to within 72 hours.
- Private health care information sent over the Internet may be intercepted by hackers. The pediatrician did not use any special software (e.g., encryption technology, setting up a secure, password-protected portal) to ensure privacy and security, making it critical that patients understand the potential for information to be intercepted. Roughly 10 percent of patients expressed a concern about security when surveyed.
- Using the system: Patients and families who signed the form were provided with the physician's e-mail address and could begin using e-mail. Their use of the program is described below:
- Volume of e-mails: Among the 306 families who enrolled in the program, 121 (39.5 percent) of them used the service, sending a total of 848 e-mails over a 2-year period, which averages to roughly 7 e-mails per family during the 2 years. On average, the physician received 1.2 e-mails per day.
- Variation across families: Although the typical family sent an e-mail only once every 5 months or so, the family with the greatest usage sent an average of five e-mails each month.
- Reasons for using e-mail: The most popular use for e-mail was to provide an update on the patient (43.1 percent of all e-mails), ask a medical question (27.5 percent), or get a test result (27.5 percent). By contrast, telephone calls during the same time period were more likely to ask about test results and less likely to provide a patient update, suggesting that families relied disproportionately on e-mail for providing medical updates (updates that in some cases would likely not have been provided over the phone), but preferred getting test results over the phone. Examples of medical updates include discussion of psychosocial issues and relaying information about new or recurring symptoms. In some cases, the physician has requested that photos be sent to him as e-mail attachments to help him to understand symptoms, such as periodic rashes, thus saving patients (some of who lived 2 hours away) from coming into the office.
- Timing of use: Approximately 40 percent of e-mails were sent after regular office hours.
- Physician response time: The pediatrician checks e-mail several times a day during breaks in his schedule, thus allowing him to respond to most messages within a few hours, well ahead of the 72-hour "deadline" listed on the consent form. By contrast, the physician usually does not respond to phone calls until the evening, as it is too difficult to predict how long a call will take (and thus returning phone calls does not fit well into short breaks), and it can often be difficult to reach a family during normal office hours.
- Introduction of text messaging: In August 2010, the office started to allow parents and the pediatric population age 14 years and older to directly text message their physician.
References/Related ArticlesRosen P, Kwoh CK. Patient-physician e-mail: an opportunity to transform pediatric health care delivery. Pediatrics. 2007 Oct;120(4):701-6. [PubMed]
ResultsThe pediatrician-patient/family e-mail program increased access to the doctor and improved patient/family perceptions about the quality of care, while not imposing a significant additional burden on (and potentially even saving time for) the physician. In August 2010, they added text messaging as another way to increase access to the doctor. Specific findings include the following:
Moderate: The evidence consists of evaluation of the use of the e-mail system along with surveys evaluating patient/family satisfaction with the system.
- High levels of patient/family participation: More than 93 percent (307 out of 328) of families accepted the invitation to participate in the email program, with lack of access to e-mail and preferring the telephone being the main reasons for those few families choosing not to participate. In addition, over time, the program has engaged more teenagers to contact their physicians directly using electronic communication including text messaging. While teen patients embraced this type of communication, they found that most families embraced it as well. They are currently surveying the families on their experience with texting. E-mail communication continues to be popular among families. The doctor is currently receiving approximately 10 to 12 e-mails per day and one to two text messages per day since the inception of the texting program in August 2010.
- High levels of patient/family satisfaction: Fifty-seven percent of users "strongly agreed" that the e-mail system enhanced access to their child's doctor, whereas 29 percent "agreed," and only 4 percent "disagreed" or "strongly disagreed." In addition, 80 percent of users "strongly agreed" or "agreed" that the system adds to the quality of communication with the doctor, with only 4 percent "disagreeing" or "strongly disagreeing." Eighty-four percent of users believed that other physicians should offer the same kind of service.
- Faster response: As noted earlier, the physician typically responded to e-mails within a few hours but did not return calls until the evening. In addition, because of delays in receiving telephone messages (which first go through office staff, then to a nurse, and then to the doctor if the nurse cannot handle the issue) and in reaching the family, many patients and families have to wait several days after leaving a message before actually speaking to the doctor.
- Limited physician burden (and likely a time saver): Comparing phone call and e-mail response time, the physician found a time savings. Analysis shows that he read and replied to the typical e-mail in slightly more than 2 minutes (132 seconds), with the range being from 4 seconds to roughly 12 minutes. The typical phone call during the same time period took just over 5 minutes to respond to (with a range from 36 seconds to 23 minutes), not including the additional time required for follow up calls when the physician was unable to reach the family the first time. Although data are not available on the extent to which patient/family e-mails replaced telephone calls, it stands to reason that in the absence of the system, the physician would have had to respond to more calls. In fact, an evaluation of phone calls over a 6-month period found that among the 95 families who used the telephone to ask a question, only 21 (or 22 percent) also sent an e-mail. This suggests that most families used one system or the other, not both. Although this study did not specifically address the question of e-mail service reducing the number of calls to the office, other studies of patient-physician e-mail have found that use of e-mail results in reductions in telephone volume.3
- More reliable communication: In contrast to e-mails (which reach their intended audience with almost 100-percent reliability), phone calls sometimes never reach the patient or family. An analysis of 166 phone calls to the pediatrician found that, in 17 cases (10.2 percent), the doctor was unable to reach the family or their answering machine, even after multiple attempts to do so.
- Little inappropriate use: Only 5.7 percent of the e-mails were for matters that were an urgent concern, whereas 0.2 percent were for emergency situations that required medical attention relatively quickly. In the urgent cases, the situation did not require immediate care but rather needed to be dealt within with a few days. In the emergent cases, medical attention was required the same day. More important, for all emergency e-mails and the vast majority of urgent ones, those sending the e-mail did so because their prior experience in communicating with the pediatrician had taught them that e-mail communications elicit a faster response than using the telephone, which, as noted earlier, has many problems that lead to a slow response.
Context of the InnovationThe pediatrician went into practice in 2003 and quickly discovered that the office phone system was neither efficient nor user-friendly. One of the doctor's first changes was to eliminate the automated system that put patients on hold and required them to navigate by pushing various buttons on their telephone keypad. This system was replaced with two members of the office staff answering all calls personally. However, this system still had problems, because most messages had to be sent to a nurse, who often did not see the message for 4 to 6 hours after the initial call. If the nurse could not answer the question, the message was passed on to the doctor, but often not until the following day. The physician would typically not return calls until late in the day, both because of the difficulty in reaching families during the day and because brief breaks in the doctor's schedule did not provide enough time to have a conversation of uncertain length. The physician's initial call to a family often ended up in voicemail, as did the patient's return call, thus leading to a cycle of telephone tag that often lasted 2 or 3 days before the family was finally reached. The net result was the creation of a lot of stress for patients and families and significant amounts of time spent by the doctor, nurses, and office staff in responding to a single phone call.
Frustrated with the inefficiencies of the system, the pediatrician began researching physician-patient e-mail, and discovered that the vast majority of patients are interested in it. The Institute of Medicine had also endorsed the practice in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century.4 His research also identified a number of concerns and fears that physicians have about e-mail communications, including the time involved (e.g., the fear of being overwhelmed with e-mails), the potential for being sued, the impersonal nature of written communications, lack of reimbursement, and the like. The physician shared many of these concerns, but he also was unsure whether they were legitimate fears or merely represented fear of the unknown. The physician had always found e-mail to be an excellent means of efficiently communicating with his colleagues at the hospital, and intuitively he believed the same could be true for patients. So he decided to test the idea in his own practice.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Meeting with the hospital's legal department: The pediatrician met with the legal department at Children's Hospital of Pittsburgh to discuss legal issues related to patient-physician e-mail. The department advised him to have all patients/families sign an informed consent form that clearly laid out guidelines and other issues related to use of e-mail communications, including the potential for security breaches.
- Developing the consent form: An existing form that was developed for telephone communications between physicians and patients was modified for e-mail communications.
- Summary education form: In addition, a one-page document was developed that clearly laid out the key points related to using e-mail to communicate with the physician, including the need to be concise, the 72-hour turnaround time, and the need to use alternative means of communication for urgent and emergent situations.
Resources Used and Skills NeededOther than the upfront time necessary to meet with the legal department and to develop the consent and education forms, this innovation requires little or no financial resources or special skills. As noted earlier, on an ongoing basis, the system seems to be a time saver rather than requiring additional resources.
Getting Started with This Innovation
- Have patients sign a consent form that clearly lays out the guidelines for using the system. The form should discuss when not to use the e-mail system (e.g., for urgent/emergent situations), expected response time, and whether the e-mail communication will become a formal part of the patient's medical record.
- Consider developing or purchasing systems that provide protection against privacy and security breaches, such as a secure portal with password protection and/or encryption. If such security is not provided, be sure that the informed consent form and other educational materials highlight the potential for information to be intercepted by hackers.
Sustaining This Innovation
- Recognize that consumers will develop expectations based on how quickly they receive responses. The pediatrician checks his e-mail several times a day (including on weekends) and responds to most messages within a few hours. Patients and families may get used to that sort of response time and begin to expect it.
- Politely alert patients and families if they use the system inappropriately (e.g., inadvertently including the physician on a mass distribution list), and request that they take steps not to use the system in that way again.
- Consider screening e-mails (or having a nurse or office staff member screen them) several times a day to make sure that there are no situations that require immediate attention. Despite the best educational efforts, some patients/families may use the system for urgent/emergent situations, particularly if they come to believe that e-mail communications elicit faster responses than do telephone calls.
- Develop further adoption techniques for physicians.
Additional Considerations and Lessons
- Consumers clearly want to communicate with their physicians via e-mail, but physicians remain behind the times in meeting this need.
- Physician fears about e-mail are overblown. This pediatrician's experience suggests that e-mail communications are an inexpensive way to enhance the patient-physician relationship, thus likely reducing (not increasing) the risk of legal liability. Patients have not overwhelmed the pediatrician with e-mails; in fact, the single largest user of this system sent only five e-mails per month.
- The system very likely saves time, not just for physicians but also for office staff who spend too much time answering phones and dealing with frustrated patients who feel unable to reach their physician in an expedient manner.
Use By Other Organizations
- Surveys show that 10 percent (or less) of patients have sent an e-mail to their provider.5,6 Some health systems are trying to encourage use of e-mail by physicians and patients; the Geisinger System in Danville, PA, for example, is working on a system to allow patients to send secure e-mails to their providers.7,8 In Denmark, the government now provides reimbursement to physicians for e-mail consultations with patients.9
Virji A, Yarnall KS, Krause KM, et al. Use of email in a family practice setting: opportunities and challenges in patient- and physician-initiated communication. BMC Med. 2006 Aug 15;4:18. [PubMed]
Zhou YY, Garrido T, Chin HL, et al. Patient access to an electronic health record with secure messaging: impact on primary care utilization. Am J Manag Care. 2007 Jul;13(7):418-24. [PubMed]
4 Institute of Medicine, Committee on the Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
Moyer CA, Stern DT, Dobias KS, et al. Bridging the electronic divide: patient and provider perspectives on e-mail communication in primary care. Am J Manag Care. 2002 May;8(5):427-33. [PubMed]
Kleiner KD, Akers R, Burke BL, et al. Parent and physician attitudes regarding electronic communication in pediatric practices. Pediatrics. 2002 May;109(5):740-4. [PubMed]
Hassol A, Walker JM, Kidder D, et al. Patient experiences and attitudes about access to a patient electronic healthcare record and linked web messaging. J Am Med Inform Assoc. 2004 Nov-Dec;11(6):505-13. [PubMed]
Wilson JF. Lessons for health care could be found abroad. Ann Intern Med. 2007 Mar 20;146(6):473-6. [PubMed]
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Service Delivery Innovation Profile
Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 08, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 14, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.