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* Division of General Pediatrics, Boston University School of Medicine
Harvard Medical School
Boston University School of Public Health, Boston, Massachusetts
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Objective. The purpose of this study was to evaluate the content of e-mails between providers and parents of patients in pediatric primary care, as well as parent attitudes about e-mail.
Design/Methods. Over a 6-week period, all e-mail exchanges between 2 primary care pediatricians and their patients’ parents were evaluated and coded. An exchange was defined as the e-mails between parent and primary care provider about a single inquiry. Parents also completed a questionnaire regarding this service.
Results. Of 55 parents, 54 (98%) agreed to have their e-mails with their pediatrician reviewed. The 54 parents generated 81 e-mail exchanges; 86% required only 1 e-mail response from the pediatrician, and the other 14% required an average of 1.9 responses. E-mail inquiries were all for nonacute issues (as judged by S.G.A.) and included inquiries about a medical question (n = 43), medical update (n = 20), subspecialty evaluation (n = 9), and administrative issue (n = 9). The 81 exchanges resulted in 9 appointments, 21 phone calls, 4 subspecialty referrals, 34 prescriptions or recommendations for over-the-counter medications, 11 administrative tasks, and 1 radiograph. Of 91 pediatrician-generated e-mails, 39% were sent during the workday (9 AM to 5 PM, Monday to Friday), 44% were sent on weeknights, and 17% were sent on weekends. During the study period, the 2 physicians estimated an average of 30 minutes/day spent responding to e-mail. Of the 54 parents, 45 (83%) returned the survey; 93% were mothers and 86% had completed college. Ninety-eight percent were very satisfied with their e-mail experience with their pediatrician. Although 80% felt that all pediatricians should use e-mail to communicate with parents and 65% stated they would be more likely to choose a pediatrician based on access by e-mail, 63% were unwilling to pay for access.
Conclusions. This is the first study to describe actual e-mail exchange between parents and their providers. Exchanges seem to be different from those generated by the telephone, with more e-mails related to medical versus administrative issues and more resulting in office visits. Approximately 1 in 4 exchanges result in multiple e-mails back and forth between parent and provider. Parents who have actually exchanged e-mails with their providers overwhelmingly endorse it, although they are reluctant to pay for it.
Key Words: e-mail • computers • primary care
Abbreviations: IOM, Institute of Medicine
The Institute of Medicine (IOM), in its report Crossing the Quality Chasm, articulates 6 specific aims for a 21st-century health care system.1 Care should be safe, effective, efficient, equitable, timely, and patient centered. As part of patient-centered care, the IOM specifically includes e-mail exchanges between care providers and patients as an important ingredient in a modern health care system. In addition to the IOM, many other leading health care experts have echoed the importance of e-mail.2–8 Benefits include improved patient-physician communication, enhanced patient-centered care, reduced cost, and continuous monitoring of clinical status, especially for patients with chronic conditions. Unique features of e-mail include its asynchronous nature, allowance for essentially continuous access to the health care system, full written record of communication with patients, and the ability to embed written and Internet resources for additional medical information when addressing a medical question.
E-mail stands in contrast to the telephone. Currently, the vast majority of nonvisit care is conducted by telephone. However, physicians spend an average of 60 minutes/day on the telephone, with much of this being "wasted time" (on hold or failing to make contact [M.J. Feldman, MD, written communication, May 25, 2004]). Patients also have complaints about telephone communication, with virtually all patients having difficulty reaching their doctors by telephone and many having given up trying.9
Despite numerous surveys and editorials,5,10–14 we are unaware of any published study that has described e-mail exchanges between parents and primary care pediatricians. The purpose of this study was to document and analyze all e-mail communication between 2 private pediatricians and the parents of their patients over a 6-week period and to survey parents regarding their actual experiences with e-mail use in this context.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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4700 patients. Parents of patients are mostly white, privately insured, and well educated. The study was conducted from October 1, 2003, to November 14, 2003. During that time, each e-mail from parent to physician generated a standardized response from the physician requesting study participation. Once consent was obtained, all e-mail communication between parent and provider, including the initial e-mail, was forwarded to the principal investigator of the study. In addition, a 45-item questionnaire was e-mailed to each parent enrolled in the study after documentation of consent. Reminders were sent to nonresponders by e-mail at 3 and 6 weeks after initiation of an encounter.
An encounter was defined as the group of e-mail exchanges between pediatrician and parent surrounding a single medical issue. Each e-mail exchange consisted of a single parent e-mail and a single provider response. Groups of issues were only coded as a single encounter if they were mentioned together in the initial parent e-mail. Each encounter was coded as a single unit consisting of multiple e-mails. Documentation of consent and expressions of thanks were omitted from the total number of e-mails per encounter.
E-mail outcomes were categorized based on the nomenclature developed by Poole and Glade14 in a content analysis of telephone use in pediatric primary care. Medical updates were defined as information on a clinical condition previously discussed. Subspecialty updates were used by the parent to alert the pediatrician on the progress of care by pediatric subspecialists. Medications included both prescription and over-the-counter medications recommended by the pediatrician. Physician health questions included those regarding specific medical questions and those addressing child behaviors and safety. Administrative issues were defined as those resulting in letters from the pediatrician on behalf of the patient to third parties such as insurance providers and adoption agencies.
This study was approved by the institutional review boards of Boston University School of Medicine and the Boston Medical Center.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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1 of 3 e-mailed their pediatrician >7 times in the past year (Table 3). Ninety-eight percent of respondents stated that their experience e-mailing their pediatricians had been very good or great (Table 4). When asked, parents stated that the majority of e-mail contact with pediatricians was surrounding medical issues (81%), with only 14% e-mailing for administrative requests and 5% for prescription requests. Although 80% felt that all pediatricians should use e-mail to communicate with parents and 65% stated they would be more likely to choose a pediatrician based on access by e-mail, 63% were unwilling to pay for access (Table 4).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Numerous national surveys of physicians and patients have shown that although patients favor e-mail communication with physicians, physicians are reluctant to oblige.17–19 Reasons most often cited include an increased workload, nonreimbursed time, and lack of security in Internet communication with patients. We found that the majority of parents endorse e-mail. However, despite their desire for e-mail access to physicians, nearly two thirds were unwilling to pay for the service. It was surprising that few were concerned with issues related to confidentiality.
The major content difference between the Poole and Glade analysis14 of telephone content in pediatric practice and the results of our study is that, unlike telephone calls, the majority of e-mails concerned a health issue (89% of e-mails vs 15% of phone calls). The vast majority of e-mail encounters surrounded a single parent concern or request. In addition, a surprisingly large percentage of encounters were initiated to update the pediatrician, with a total of 36% providing information from the parent with no request for assistance from the pediatrician. These updates consisted primarily of new information regarding the progression of a previously discussed medical problem or its response to therapy. Preexisting problems ranged from chronic illnesses such as asthma and food allergies to episodes of otitis media and thrush. This illustrates the benefits of e-mail in providing ongoing communication from the parent to the clinician. The IOM and other proponents have cited this as a possible benefit of e-mail.
Two other studies have examined the e-mail content between providers and patients in primary care. A study done at Kaiser Permanente in Portland, Oregon, analyzed the e-mails of 5 primary care physicians (3 internists and 2 pediatricians) and their patients over a 1-month period. Similar to our study, patients communicated directly with physicians. Results were similar to ours: 77% of e-mails from patients contained only 1 request, and the majority of inquiries concerned requests for specific medical information (26% about medication and 22% about specific symptoms or diseases). However, 20% of the e-mails were regarding actions related to medications such as requests for refills (our total was 11%).15 In a second study, White et al analyzed e-mail content between 103 attending and resident physicians practicing in an academic medical center and their patients. Once again, the majority of these e-mails addressed a single issue (83%). There were large numbers of inquiries for medical updates (42%) and health questions (13%), although there were many more inquiries (57%) that did not require the response of a physician.16 Some of the differences found in these 2 studies may be due to the intrinsic difference between pediatric and internal medicine. Additionally, in the White et al study, patients were told that e-mails would be triaged to the appropriate personnel (nurses, administrative support personnel, physicians), whereas in our study, parents were aware that their e-mails would go directly to their pediatrician and thus did not include many requests that were directed at other office staff. This highlights the impact that providing instructions to patients about the use of e-mail may have on e-mail content.
The 2 physicians involved in this study exchanged e-mails directly with the parents of their patients. We have argued previously that physicians should refrain from such exchanges and establish a central e-mail address so that incoming e-mails can be triaged similarly to telephone calls.3 This concept of e-mail triage may not be necessary. Unlike telephone calls, it seems that the vast majority of e-mails require a physicians’ response. At least in this study, parents were aware of the "privilege" of direct contact with their physician and limited inquiries to those that pertained to the clinician. A few surveyed parents went so far as to state that pediatricians should not provide e-mail to their parents if parents were to abuse the privilege.
This study has a number of limitations. Only 2 pediatricians from a suburban private practice were involved in the study. Parents in this study were well-educated and had a high degree of experience with e-mail. How these results would generalize to other parents and pediatric practices is uncertain. Although there was no use of e-mail for an acute medical problem, such a situation remains a concern of many physicians. This lack of acuity may reflect the small sample size of this study.
This study represents an initial exploration of the use of e-mail in pediatric primary care. To date, studies regarding pediatric primary care e-mail correspondence have mostly been limited to descriptions of attitudes, knowledge, and behavior toward e-mail exchange but have not described actual e-mail content. Although Sittig15 did analyze e-mails between pediatricians and parents, he also included the results of e-mail between internists and patients in the same analysis and thus was unable to tease out issues unique to primary care. Additional studies should be performed in a broad array of pediatric ambulatory care delivery systems, including both specialty and primary care. Particular attention should be paid to the use of e-mail to monitor and coordinate the care of patients with chronic conditions. Ultimately an experimental design will be necessary to assess the benefits of e-mail in pediatric practice.
The IOM has called for an increased use of nonvisit care in response to patients’ needs. E-mail may be the most efficient venue for the provision of such care.
In addition, e-mail documentation is a superior alternative to transcription of telephone care, advancing the IOM’s goal of the elimination of most handwritten clinical data by the end of the decade. Through the facilitation of parent-physician communication and provision of more efficient care, e-mail is an essential ingredient in the improvement of pediatric health care quality in the 21st century.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Address correspondence to Shikha G. Anand, MD, Boston Medical Center, 91 E Concord St, Maternity Building, Boston, MA 02118. E-mail: shikha.anand{at}bmc.org
This work was presented in part at the annual meeting of the Pediatric Academic Societies; May 2, 2004; San Francisco, CA.
No conflict of interest declared.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  P Thompson and E Carr Content analysis of general practitioner-requested lumbar spine X-ray reports Br. J. Radiol., November 1, 2007; 80(959): 866 - 871. [Abstract] [Full Text] [PDF]
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 P. Rosen and C. K. Kwoh Patient-Physician E-mail: An Opportunity to Transform Pediatric Health Care Delivery Pediatrics, October 1, 2007; 120(4): 701 - 706. [Abstract] [Full Text] [PDF]
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 J. R. Thomas and U. Shaikh Electronic Communication With Patients for Breastfeeding Support J Hum Lact, August 1, 2007; 23(3): 275 - 279. [Abstract] [PDF]
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 J. H. Stone Communication between Physicians and Patients in the Era of E-Medicine N. Engl. J. Med., June 14, 2007; 356(24): 2451 - 2454. [Full Text] [PDF]
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 T. Kind E-mail and Parent/Physician Communication AAP Grand Rounds, September 1, 2005; 14(3): 34 - 34. [Full Text] [PDF]
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