Published online October 1, 2007
PEDIATRICS
Vol. 120
No. 4
October 2007, pp.
701-706
(doi:10.1542/peds.2007-1094)
Patient-Physician E-mail: An Opportunity to Transform Pediatric Health Care Delivery
Paul Rosen, MD, MPH, MMMa,b and
C. Kent Kwoh, MDc,d
a Departments of Pediatrics
c Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
b Division of Rheumatology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
d Division of Rheumatology, Veterans Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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ABSTRACT
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OBJECTIVE. The objectives of this study were to assess the patterns of patients who use a patient-physician e-mail service, measure physician time required to answer a patient question via e-mail compared with that via telephone, and determine the satisfaction of families who are provided e-mail access to their child's rheumatologist.
METHODS. A consecutive series of patients' families were offered e-mail access during a 2-year period. Data regarding patient e-mail use were collected, including urgency of message, subject matter, message volume, and time of day of messaging. The duration of the pediatric rheumatologist's e-mail interactions and telephone interactions with patients was measured using a stopwatch. After 1 year of enrollment in the patient-physician e-mail service, families were mailed a 12-item satisfaction survey regarding their e-mail experience.
RESULTS. A total of 306 of 328 families who were offered patient-physician e-mail access enrolled, and 121 used the service. The patients sent 40% of their e-mails outside business hours. Messages that were urgent (notification of disease flare, notification of new symptoms, or parent expectation of same-day response) made up 5.7% of the e-mails sent to the physician. Messages that required emergent attention made up 0.002% of the e-mails to the physician. Answering patient questions by e-mail was 57% faster than using the telephone for the physician. The physician received 1.2 e-mails per day from patients. The families who responded to the survey agreed that patient-physician e-mail increased access to the physician and improved the quality of care. The families did not find that patient-physician e-mail distanced them from their child's doctor.
CONCLUSIONS. Patient-physician e-mail is a service that patients will use given the opportunity. The e-mail service enables physicians to answer medical questions with less time spent compared with telephone messaging. In our experience in an academic pediatric subspecialty practice, patients reported enhanced communication and access with the e-mail service.
Key Words: e-mail
Abbreviations: IOM—Institute of Medicine • PPEM—patient-physician e-mail • HIPAA—Health Insurance Portability and Accountability Act
The 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century called for care that is based on continuous healing relationships.1 In its first rule on redesign, the IOM report stated, "Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This implies that the health care system must be responsive at all times, and access to care should be provided over the Internet, by telephone, and by other means in addition to in-person visits." The IOM indicated, "E-mail communication could meet many patients' needs more responsively and at a lower cost."
Pediatricians are more likely than other physicians to use e-mail communication with their patients. However, to date, only 
30% of pediatric doctors are using patient-physician e-mail (PPEM). Meanwhile, 90% of patients would like the ability to e-mail their physician.2 The same survey found that of patients who use e-mail, 37% would pay out of pocket for the ability to e-mail their physician. One third of patients would change their doctor to get PPEM.3 Such a disparity between physician service and patient demand represents an opportunity for a transformational change in health care delivery.
What are the reasons behind the underuse of e-mail? Physician concerns regarding the use of PPEM include the following:
- Increased time to answer patient questions4,5
- Impersonal form of communication3
- Fear of inappropriate use by patients for emergencies3
- Increased liability3,6
- Discomfort with sending private health information over the Internet4,5
- Loss of revenue3
The purpose of this study was to evaluate patient use, physician time spent, and patient satisfaction surrounding PPEM.
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METHODS
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This study was conducted in an academic pediatric rheumatology practice in Pittsburgh, PA, between April 2004 and March 2006. One physician offered e-mail service to his patients during this period. The physician's e-mail address was provided after a signed informed consent was obtained. The guidelines for PPEM use were verbalized to the families in a standardized manner by the rheumatology practice nurses. The written consent included the following guidelines for patients: - E-mail is not to be used for an emergency or time-sensitive situation.
- E-mail communications should be concise.
- E-mails may be forwarded to other members of the health care team involved with the child's care.
- E-mail correspondence will become part of the child's medical chart.
- E-mail response will be within a 72-hour time frame.
- Private health care information sent over the Internet may be intercepted by hackers.
The study was approved by the University of Pittsburgh institutional review board.
During a 2-year enrollment period (April 2004 to March 2006), families were invited to enroll in the e-mail service. Families who agreed to enroll were explained the guidelines of e-mail use and asked to sign a written consent form. Families who declined enrollment were asked the reason they were not interested. The date the families enrolled was recorded. The e-mail messages during the 2 years were saved electronically for review. The content was evaluated for the level of urgency. The date and time when the e-mails were sent to the physician were tracked.
During a 6-month period, the time required for the physician to answer questions via telephone (149 calls) and via e-mail (109 e-mails) was measured. The diagnosis of the patient involved with each call and e-mail was recorded. A Student's t test was used to evaluate whether the type of communication used varied with the diagnosis. A Student's t test was also used to evaluate whether the type of communication used varied with the message type. The interactions were measured with a stopwatch, and the time was recorded to the nearest 1 second. Time recorded for each e-mail encounter included the time spent reading the e-mail and typing and sending a response. Time recorded for each telephone encounter included the time spent dialing the telephone number and completing the call. The time spent on calls with no answer was also measured. The mean times for the 149 calls and for the 109 e-mails were calculated and compared using a 
2 test.
One year after starting the e-mail service, a letter was sent to the 175 enrolled families announcing that a 12-question survey would be coming in the mail the next week. The surveys were sent with a stamped, self-addressed envelope. Instructions were given to maintain anonymity by not writing the name or return address on the survey.
The survey included 11 statements with regard to physician access, understanding of medical tests, threat of hackers, and overall satisfaction with the e-mail service. The families recorded their level of agreement with each statement on a 5-point Likert scale from "strongly agree" to "strongly disagree." A final question asked about frequency of use of the e-mail service. Families were also asked for their open-ended feedback.
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RESULTS
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During a 24-month period, 328 families were offered e-mail service. Twenty-one families declined enrollment; 10 (3.0%) of the families declined e-mail service because they did not have a computer or e-mail access. Nine (2.7%) families declined because they preferred always to use the telephone to communicate with their physician. Two families declined e-mail service without specifying a reason. A total of 306 (93.3%) families signed informed consent and enrolled in the e-mail service. Of the 306 families enrolled, 121 (39.5%) e-mailed the physician at least once during the 2-year period. A total of 848 patient e-mails were sent to the physician during the 24 months (730 days) for an average of 1.2 e-mails per day to be answered by the physician. On average, each consented family sent 0.19 e-mails per month of enrollment. The family with the greatest e-mail usage sent 5.0 e-mails per month of enrollment.
During a 6-month study period, there was no significant difference in the patient age or race found between parents who placed telephone calls and those who sent e-mails. No family who was on a public health insurance plan sent an e-mail (Table 1). There was no significant difference in diagnosis type between families who placed telephone calls and those who sent e-mails (Table 2). There were significantly more requests for test results coming in by telephone. There were more patient updates provided by e-mail messaging (Table 3). We found that of the 95 families who used the telephone to ask a question (149 calls), 21 (22%) also sent an e-mail message during the same 6-month time frame.
During the 6-month time measurement period, data on 109 e-mails and 149 telephone calls were collected. The time required for the physician to read an e-mail and type a response ranged from 4 to 714 seconds (mean: 132.1 second). The time required for the physician to complete a telephone call ranged from 36 to 1392 seconds (mean: 309.2 seconds). This difference in time was statistically significant (P < .0001). In addition to the 149 calls that were successfully returned by the physician, there were 17 calls for which the physician was unable to reach the family after multiple attempts (166 total patient calls). For the 166 telephone calls, 23 (13.9%) required >1 call to reach the family or an answering machine. Seventeen (10.2%) of the 166 calls failed to reach a person or a machine.
During 24 months, of the 848 e-mails, 48 (5.7%) regarded an urgent concern, such as notification of a disease flare, new symptoms, or a matter for which the parent expected a response the same day (Table 4). Two of the urgent e-mails were emergent, such that they required medical attention the same day. A total of 335 of the 848 (40.0%) e-mails were sent by families after regular office hours.
One year after initiation of the e-mail service, a patient satisfaction survey was conducted. A total of 72 (41.1%) of the 175 mailed surveys were returned; 64 of the 72 surveys were fully completed (Tables 5 and 6).
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DISCUSSION
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Our study evaluated PPEM with regard to patient use, physician time, and patient satisfaction in an academic pediatric subspecialty practice. Borowitz et al7 examined PPEM in a pediatric gastroenterology setting, but the focus was on distant patients without follow-up communication. In their study, the time required to answer e-mail consultations was almost twice ours (237 vs 132 seconds). However, their focus was to provide a consultation service for patients who were unknown to them. Our focus was to extend our care to patients who were already in our practice.
Pediatricians have done better than most physicians in the adoption of PPEM; however, the technology is still grossly underused. Many physicians are concerned about the amount of time required to respond to e-mails. E-mail communication could be viewed as yet another physician task, thereby extending the physician workday. However, our study shows that compared with a telephone call, e-mail response takes the physician 57% less time on average to complete. In this context, PPEM could be viewed as a time-saving tool. PPEM would not only serve to save the physician time but also to save the office staff time by avoiding fielding telephone calls that would eventually have to be routed to the physician. Therefore, PPEM could improve physician efficiency and have a net benefit on office efficiency.
E-mail may be viewed as an impersonal form of communication. The voice cues that reflect emotions during a conversation are lost in e-mail communication. However, the parents who responded to our survey believed that e-mail added to the quality of communication with their child's doctor. They also believed that e-mail facilitated understanding of medical tests. The parents did not believe that e-mail distanced them from their child's doctor. Overall, the data from the surveys were reflected in the qualitative remarks regarding the e-mail service. These findings are significant in light of the results of Stewart et al,8 who noted that improvement in patient-physician communication leads to improved patient compliance, satisfaction, and health status and a reduced need for diagnostic tests and referrals. Chen-Tan et al9 reported that online communication led to more messages from patients who contained updates without need for physician response and more messages with psychosocial content compared with telephone calls. They concluded that online messaging provided a foundation on which to promote the IOM's call for "care based on continuous healing relationships."
Our study did confirm that despite informed consent, some families will use e-mail to communicate urgent concerns. Of the 848 e-mails sent, only 2 required emergent medical attention the same day. Both of those e-mails had been sent by the same family. Although our consent form indicated that e-mail responses would be sent within 72 hours, almost all physician responses were sent within 24 hours. In addition, many responses during regular business hours were sent within 2 hours. At the same time, our telephone triage system routed patient calls from patient to secretary to nurse to physician. The routing process could take several hours depending on the workload of each staff member. Our e-mail process bypassed the support staff, leaving the physician response time as the only bottleneck. The patients who used e-mail instead of telephone to communicate urgent concerns may have believed that the message would get through faster than through our telephone system. Thus, our efficient e-mail system may have emphasized inefficiencies in our telephone triage system; therefore, our short e-mail response times may have encouraged inappropriate communication of urgent concerns.
Increased liability may be a concern for some regarding e-mail communication with their patients. We know that liability is often correlated with the quality of a relationship. The patient-physician relationship hinges on good communication. Anything that enhances this communication should reduce the risk for misunderstanding, preventable injury, and liability. Many busy office practices often have busy telephone signals or automated telephone matrices that cause the patients to navigate for 5 to 10 minutes with push-button options. These delays are barriers to communication and can engender frustration when trying to communicate with the physician. E-mail removes the constraints of telephone communication by giving the patient an opportunity to start a dialogue 24 hours a day. Our result that 40% of patient e-mails were sent after office hours or on weekends and the result of 58.2% found by Anand et al10 speaks to the fact that parents of pediatric patients would like to initiate a communication outside regular business hours.
Threats to security and privacy are real. In its Health Insurance Portability and Accountability Act (HIPAA) policy statement, the federal government addresses the risk of sending private health information electronically. E-mail encryption through a "public key" allows heightened protection against "hackers."11 The federal government does recommend encryption technology to minimize the interception of private health information. Detailed guidelines on how to reduce risk when sending private health information electronically have also been published.12 Our e-mail service was not ideal because it did not provide for security with encryption technology. The patients were reminded of the risk for stolen private health information when they signed informed consent. It is interesting that only 10% of patients responded that they agreed or strongly agreed with the statement that they worried about hackers.
Reimbursement for e-mail communication with patients is not widespread. In the areas in which e-mail communication is reimbursed, the advantage is that the documentation of the encounter has taken place and a copy can be saved to the paper or electronic medical record. PPEM has been reimbursed in some cases of chronic disease management, for which the impact of improved patient-physician communication reduced acute care costs through better management.13 As more health plans see value in PPEM, reimbursement for electronic communication may become more common.
Our study had several limitations. It was based on the experience of 1 pediatric subspecialist in an academic children's hospital; therefore, our results may not be applicable to practices in other pediatric subspecialties or in general pediatrics. Another limitation of our study was that we did not measure the impact of the e-mail service on the number of telephone calls to our office. Although we know that the duration of an e-mail was shorter than the duration of a telephone call, we cannot comment on whether the e-mails reduced the number of telephone calls. The survey instrument that was used to evaluate patient satisfaction was not a validated tool. In addition, only 41% of the surveys were returned, introducing a sampling bias to the results. The low number of surveys returned may be because only 39.5% of the families were using the e-mail service. We did not survey the patients regarding their willingness to pay for the e-mail service.
Our study shows that PPEM is quantitatively faster than telephone discussion. The patients who responded to our survey were overwhelmingly positive about their experiences. The majority of patients who signed up for the e-mail service never sent a single e-mail to their physician. Patients who did send e-mails did not overburden the physician. The patients involved had chronic conditions, requiring ongoing communication. Since our study, our practice has seen attending physician adoption of PPEM increase from 25% to 80%. In addition, we have redesigned our telephone messaging system to make it more efficient for families.
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CONCLUSIONS
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Our study may have limited generalizability. For some physician practices, a staff-based triage system may be more efficient than a non–triage-based system.14 However, the comments of the families who used the service demonstrate that PPEM is one method of improving communication and providing consumer-driven health care. Pediatricians are leaders when it comes to using PPEM. However, there is still an enormous opportunity to use technology in the treatment of patients. Given the nature of family-centered care for pediatric patients, pediatricians and pediatric subspecialists are well positioned to transform health care delivery.
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ACKNOWLEDGMENTS
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Financial support was provided by a Children's Arthritis Network grant, sponsored by the Arthritis Foundation Eastern Pennsylvania Chapter.
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FOOTNOTES
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Accepted May 10, 2007.
Address correspondence to Paul Rosen, MD, MPH, MMM, University of Pittsburgh School of Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, Division of Rheumatology, 3705 Fifth Ave, Pittsburgh, PA 15213-2583. E-mail: paul.rosen{at}chp.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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ABSTRACT
METHODS
