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October 2009
Effective Patient-Provider Email: A Pediatrician's Experience
With Paul Rosen, MD, MPH, Children's Hospital of Pittsburgh

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Welcome to the AHRQ Health Care Innovations Exchange Chats on Change

Today’s Chat is Effective Patient-Provider Email: A Pediatrician’s Experience.

With Paul Rosen, MD, MPH, MMM Children’s Hospital of Pittsburgh

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What Is the Health Care Innovations Exchange?

Searchable database of service innovations

  • Includes successes and attempts
  • Wide variety of sources ? including unpublished materials
  • Vetted for effectiveness and applicability to patient care delivery
  • Categorized for ease of use: extensive browse and search functions
  • Innovators’ stories and lessons learned
  • Expert commentaries

Learning opportunities

  • Learning Networks: A chance to work with others to address shared concerns
  • Educational content
  • Web Events featuring innovators, experts, and adopters

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Effective Patient-Provider Email: A Pediatrician’s Experience

How We Did It:

  • We made patients/families aware of our e-mail option
  • We obtained informed consent
  • We distributed guidelines for appropriate use
  • We provided patients/families who signed form with e-mail address for use

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Innovation Results

  • High levels of patient/family participation
  • High levels of patient/family satisfaction
  • Faster physician response
  • Limited physician burden (and likely a time saver)
  • More reliable communication
  • Little inappropriate use

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Questions or Comments

Contact us: info@innovations.ahrq.gov
Subscribe to receive e-mail updates: http://innovations.ahrq.gov/contact_us.aspx

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Transcript

Judi Consalvo (AHRQ Host):  Hello, everyone. Welcome to the AHRQ Health Care Innovations Exchange Chats on Change, which is a new series that will allow the audience to talk directly to a featured innovator and to each other. We look forward to a lively exchange!

Our next Chat on Change will be in January 2010 on an innovation topic that will be very much on people’s minds at that time. We will keep you posted on registration details.

Please see the rotating slides on your screen for more information on the AHRQ Health Care Innovations Exchange and links to our Web site and to Dr. Paul Rosen’s innovation on patient-provider e-mail.

We’re very pleased Paul agreed to be our very first moderator for Chats on Change. Paul is clinical director of rheumatology at the Children's Hospital of Pittsburgh of UPMC and has published in the journal Pediatrics on patient-physician e-mail communication.

Paul, thanks for joining us.

Paul Rosen (Innovator/Moderator):  Great to be here; hello everyone.

What do people think of having your MD 'one click away?'

Mary N.:  I'm longing for that kind of connection!

D. C.:  Efficiency.

Shannon F.:  It would be very convenient.

Paul Rosen:  Our parents of pediatric patients have reported improved access since we started email in 2004

Robin P.:  I think most questions can be answered without a prolonged wait in a waiting room.

Josh B.:  Security?

Paul Rosen:  On efficiency, it has saved me time and decreased phone tag.

Elaine S.:  What do you do with people who want a lot of info?

Robin P:  HIPAA Issues with patient identification?

Sharon Y.:  How do document conversations?

Paul Rosen:  When we first started, our system was not secure; the lawyers advised us on consent forms to notify patients about hacking.

Paul Rosen:  The email is the documentation and we scan these into our electronic record.

Erin B.:  This is also something we have enjoyed at our organization, but the demand has increased so it has added to providers’  workdays.

Paul Rosen:  Going forward, we are now implementing a more secure system.

D. C.:  How are you reimbursed for your time?

Paul Rosen:  Erin: do you know if the increase in emails has resulted in fewer phone calls?

Josh B.:  Do you get paid for the consults?

Paul Rosen:  Just like time on the phone, we are not reimbursed for email.

Elaine S.:  Reimbursement is also an issue with phone calls. If e-mail saves on phone calls, could be win-win.

Paul Rosen:  Our system is experimenting with e-visits where there would be reimbursement.

Laura M:  do you have any issues with patients over-using the email? how do you handle that?

Robin P.:  Do you limit your emails to specific types - RX refills, appts., etc?

Shannon F.:  as the system becomes more secure, have you noticed more patients and families are willing to use email communication?

Mary N.:  Paul: Even though your innovation seems like old news there are so many providers who do not interact with their patients this way. Do you know the exact numbers that do/don't?

Paul Rosen:  I have had some patients send a lot of emails.  I will either answer the emails or pick up the phone at that point.

D. C.:  What is your average turnaround time for response?

Sharon Y.:  Do you market to all patients, or just offer to those who seem savvy?

Paul Rosen:  My understanding is that 90% of patients want their doctor's email, but less than 25% of MDs provide the email.

Josh B.:  Have you asked patients how much they would pay for the evisit?

Paul Rosen:  During the day, I usually answer email within 2 hours; on weekends about 12 hours.

Erin B.:  How have your patients adjusted to the evisits, since they are billed?  We have angry patients since they could email last year for free.

Paul Rosen:  I give all my patients my email--95% have internet.  Less than 40% ever email me.

We are still emailing for free in my practice at this point.

Russ M.:  Paul, Has this spread to other clinicians in your practice or system?  What reactions have your colleagues had?

Paul Rosen:  We have not asked patient how much they would pay.

Elaine S.:  What lies in the future given the rise of texting?

D. C.:  Do the patients who use email have distinctive characteristics, e.g. chronic ailments like asthma?

Paul Rosen:  In the beginning, I was the only one doing the email.  Now 80% physicians use email with patients.

The range of emails can be from chronic patients or regarding one-time visits.

Josh B.:  When does it become an evisit verses an email?

Erin B.:  Has it added to your day on top of seeing patients?

Paul Rosen:  I answer the email through the day and I still finish the same time.

Deb P.:  Is the emailing the responsibility of the on-call doctor, or the doctor directly contacted by the family?

Sharon Y.:  Can you cite problems that were avoided because of e-mail comm with a patient(s)?

Mary N.:  Do you think that less than 40% email me because you are a specialist? That is, would a primary care pediatrician have more emailing parents?

Paul Rosen:  Regarding an e-visit, I believe there are strict guidelines negotiated by the 3rd party payer with the physician.

D. C.:  Do you ever delegate to your staff to monitor the email and triage what you need to see vs. more routine issues?

Paul Rosen:  I think the emails come when there is an acute problem.  For example, I have been getting more emails about H1N1.

Paul Rosen:  My next project would have to be to use Twitter to announce when we have the vaccine.

Paul Rosen:  If a question concerns a social work or nursing issue, I forward it.

Elaine S.:  Does anyone online currently use Twitter?

Mary N.:  Speaking of Twitter, do you engage with your patients/parents through any type of Web 2.0 or social media tools?

Paul Rosen:  What about Facebook, MySpace, text messaging, LinkedIn?

D. C.:  Do many of your patient emails get lost in your spam?

Erin B.:  We just use email at this time.

Paul Rosen:  I engaged with patients on a blog sponsored by the Vasculitis Association, but that was just once.

Paul Rosen:  I have not had any significant spam issues.

Erin B.:  Have you seen overuse of the email concept by patients?

D. C.:  Erin, what have been your challenges?

Paul Rosen:  For more than 95% of the patients, it has not been overused.

Judi Consalvo:  I want to break in a moment for people to respond to the following poll so we can get a better feel for our audience.

Paul Rosen:  I have used the email to get patient feedback about our service as well.

Judi Consalvo:  Thank you all for your participation.  Researchers lead the group followed by Other, Health Administrators and Physicians. 

Paul Rosen:  For example, I sent a 1 question survey about our appointment hours.  40% responded that they needed broader hours so we changed our appointment times based on that feedback.

Erin B.:  Over 40% of our patient population has the ability to email/evisit us at our clinic.  We see a high volume of questions and concerns come through email.  A majority is appropriate, but it has added to our physician's day.  We also have implemented evisits to charge for the physician time. We are trying to find a model to reduce our physician time spent working.  We think it’s a great tool but need to find the best model.

Paul Rosen:  This morning, the head of the lab asked me to email a sample of our patients to get feedback on the customer service in the lab.

Mary N.:  Any improvements in outcomes because of the improved communication?

Paul Rosen:  Our data just show improvements in parent satisfaction and reduction in time spent on the phone.

Russ M.:  Do you ever use e-mail to send clinical info like lab results or images to patients?  What about appointment reminders or other administrative info?

D. C.:  Paul/Erin...do you have a patient portal too, or just email communications?

Shannon F.:  Erin, what is the patient population at your clinic?

Paul Rosen:  Our secure portal is starting this week.

Elaine S.:  Erin, do you triage questions so that some are answered by physicians, others by NPs or PAs, etc.

Paul Rosen:  Patients email all the time about lab results and I respond by email.

Erin B.:  We are a primary care clinic with a population of 12,000 patients.

Deb P.:  How do you measure patient satisfaction?

Mary N.:  Are you thinking about a research study to explore impact on outcomes?

Elaine S.:  Erin, how many practitioners?

Anne I.:  Are emails and your replies automatically uploaded into the pt's EMR?

Paul Rosen:  We had done a pre- and post- email implementation survey.  However, you can tell by the expression on the face when you hand them the email.

Christina W.:  As a patient my PCP does have her MA triage her emails. And she has taught me to be very clear in the email subject line about what I need so the email is triaged easily and appropriately.

Erin B.:  We have a website where they generate the emails, also a place where they can receive their test results.  We have 2 practitioners and have all the emails automatically upload to our EMR.

Elaine S.:  Raises a good question on how this is systematically included and perhaps mined by EMRs.

Paul Rosen:  Currently, no automatic upload, but we are changing to that now.

D. C.:  Are the emails narrative, or any pick lists for easy aggregation/analysis?

Paul Rosen:  The emails are narrative.

Erin B.:  We have guidelines and recommendations, but they come in as narrative.

Shannon F.:  is it pediatric-focused? i was just wondering if you patient acuity/complexity was different than Dr. Rosen's...could possibly relate to the time burden on your docs.

Erin B.:  Based on condition, our nursing staff can respond by sending questionnaires to complete for the provider.

Elaine S.:  How long are emails typically or do they vary tremendously?

Josh B.:  Do you do video messaging or live video consults?

Anne I.:  Is there a type of "legal disclaimer" statement on each outgoing email? If so, please describe.

Paul Rosen:  Our guidelines are: be concise, be aware of hackers, be aware support staff can see email, it will go into EMR, allow 72 hrs for response.

Paul Rosen:  Emails vary; it has been reported that patients report more psychosocial info via email than phone/office visit

D. C.:  Any story that stands out when it was great? When it did not work?

Paul Rosen:  For example, a family said nothing about a case of abuse in the office but then emailed me the info a couple of days later.

Paul Rosen:  We have not yet gotten into video.

Paul Rosen:  I had one person email me that their child was having difficulty breathing.  Fortunately i saw the email a few minutes later.

D. C.:  yikes...

Anne I.:  How would a mistakenly directed email be handled (sent to wrong person)?

Paul Rosen:  I think parents learned they could reach me by email quickly whereas our phone messages get triaged and a response can take longer.

Paul Rosen:  Anne: do you mean if I sent an email to the wrong patient?

Anne I.:  Yes.

Paul Rosen:  I would then have to call the family and explain and apologize.

Paul Rosen:  I think we have time for a few more comments/questions before we finish up.

Mary N.:  Guess docs use of email is like teachers: some are on email all the time, some don't look at it once a week if you're lucky!

Paul Rosen:  My sons' teachers use email and we love it.  People are busier now than they used to be.

Josh B.:  Is it HIPAA compliant to email when a patient signs an informed consent form or are you using a secure email system?

Sharon Y.:  What is your total volume of patients? That is, to compare with a primary care peds practice?

D. C.:  What was the most challenging issue to start this program?

Anne I.:  Is the email system encrypted?

Paul Rosen:  We are moving to a secure system.  We were not using a lock-and-key system.  Our lawyers advised us that a consent form was permitted.

Russ M.:  How can people get in touch with you if they have additional questions?

Paul Rosen:  We do 4,000 visits/year

Paul Rosen:  Email me, of course: Paul.Rosen@chp.edu.

Paul Rosen:  Thank you everyone for your great comments!

Josh B.:  How many visits per day are in office verses email?

Paul Rosen:  30 visits/ day.  I typically get 5 emails/day.

Deb P.:  Thanks for the chat!

Josh B.:  Thank you.

Erin B.:  Thanks so much for your information!

Judi Consalvo:  Thanks, everyone. On behalf of the AHRQ Health Care Innovations Exchange, I would like to thank you for joining us for Chats on Change.  We have had a lot of terrific questions, suggestions, and other valuable input on patient-provider e-mail.  Paul, thank you for your great contribution to our first Chat on Change.

In a few weeks, the entire transcript of this Chat will be available on AHRQ Health Care Innovations Exchange Web site.

Please take a moment to fill out the survey that will appear once the chat closes.

Please visit our Web site at:  http://www.innovations.ahrq.gov/