Parent and Physician Attitudes Regarding Electronic Communication in Pediatric Practices

METHODS

Two survey tools were developed, one for patients/parents and the other for physicians (available on request). Parents were approached consecutively in the waiting rooms of participating practices in an integrated pediatric health care delivery system. Parents were interviewed on weekdays as they waited for appointments with their child’s physician. Physicians were interviewed at their convenience. Both sets of surveys were administered via face-to-face interview. Demographic information, access to e-mail, and the subjects’ attitudes regarding e-mail use for physician-patient communication were obtained. Strength of feeling was measured using a 0 to 100 visual analog scale.¹² Beliefs and attitudes regarding confidentiality and safety of e-mail use were measured on a 0 to 100 scale, with 0 being not at all concerned and 100 being very concerned. The data were entered into an Access database without participant identifiers. The protocol and forms received approval from the local institutional review board.

RESULTS

Interviews were initiated for parents of 325 children, 161 at 4 general pediatrics (GP) offices and 164 at 4 specialty pediatrician (SP) offices. Sixteen surveys were incomplete as a result of patients’ being called in for their doctor’s appointment or parental refusal. Thus, a total of 309 surveys were fully completed, and answers that were available for all surveys were included in the analysis. A few parents declined participation in the interview, but no data are available about these families.

Table 1 compares demographic characteristics: ethnicity, age, education, and annual income for parents and ethnicity, age, gender, and patient load per week for physicians among GP and SP offices. The proportion with e-mail access for parents and physicians at each office type is also compared in Table 1. Specialties represented were hematology, endocrinology, surgery, and otolaryngology. No significant demographic differences were noted with the exception of parental age (P < .001) and family annual income (P = .028).

Fifty-seven percent of parents at GP offices and 66% of parents at SP offices had access to e-mail at work, home, and/or another location. No difference in access to e-mail between parents at GP and SP offices was noted (P = .126). Table 2 displays the effect of parental age, education, and family income on parental access to e-mail. After taking into account parent education level and family income, the odds that those who were aged 41 to 50 years had e-mail access were less than half of the odds that those who were 31 to 40 years had e-mail access (P = .028). The odds of having e-mail access for those who were currently attending college or had a college degree were 3 to 4 times greater than those who had only a high school diploma, even after adjusting for age and income (P < .05). The odds of having e-mail access for those who had the lowest annual family income (<$20 000) were 7 times less than those who had annual incomes between $20 000 and $35 000, whose odds were, in turn, 3 times less than the odds for those who had family incomes between $35 000 and $60 000 (P < .001, P = .004). Also, the odds of having e-mail access for those who earned >$100 000 annually were almost 5 times greater than for those who earned between $35 000 and $60 000 (P = .059). In general, e-mail access increased as parental education and annual family income increased.

Seventy-one percent of families at GP offices and 76% of families at SP offices expressed an interest in using e-mail to contact their physician or physician’s office. Figure 1 reveals that parents showed an equally high level of interest for using e-mail to schedule appointments, get test results, refill prescriptions, ask questions about their child’s health, get additional information about their child’s condition, and discuss their child’s symptoms.

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Fig 1.

Reasons for interest in using e-mail for patient-physician communication. Physicians were categorized into those who would use e-mail themselves to communicate with patients (Self use, n = 10) and those who would allow their office staff to communicate with patients by e-mail (Office staff, n = 20). Their responses to the questions about potential uses for e-mail contact are compared with the parents’ responses (Parents, n = 246).

However, when asked, “How concerned are you that by using e-mail for medical issues, personal medical information about you or your child will become available to people who should not have access to the information,” parents at SP offices expressed significantly more concern about confidentiality than did parents at GP offices (median_SP = 95 vs median_GP = 70; P = .01). Figure 2 displays histograms of the level of concern associated with using e-mail for communication with their physician office by type of practice. Twenty percent of parents at GP offices expressed little to no concern, whereas 55% expressed a great deal of concern. Similarly, at SP offices, 28% of parents expressed little to no concern, whereas 43% of parents at SP offices were highly concerned. Although there is a wide range of concern, this bimodal distribution from both types of practice indicates that the parents had either great concern or very little concern about the confidentiality of e-mail. When asked, “How safe do you think e-mail is for privacy?” where 0 is unsafe and 100 is totally safe, the parents responded with a mean score of 50 for both the SP and GP groups.

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Fig 2.

Histograms of the level of concern among families by type of practice. Parents were asked to identify their level of concern about e-mail confidentiality using a visual analog scale of 0 to 100, where 0 indicates no concern and 100 indicates very concerned.

SPs had significantly greater access to e-mail than GPs (100% vs 74%; P = .02). Seventy-nine percent of both GPs and SPs did not want to communicate directly with patients via e-mail. Physicians were more open to having their office staff members communicate with patients via e-mail. Sixty-four percent of SPs and 18% of GPs were inclined to have their office staff use e-mail to communicate with patients, whereas 21% of SPs and 64% of GPs were undecided about this option. Only 18% of GPs and 14% of SPs said that they would not allow it.

Physicians in general believed that e-mail communication with patients would increase their workload. There was no substantive difference between physician type and potential uses for e-mail; therefore, responses for GPs and SPs are combined. Of the 10 physicians who responded that they would personally use e-mail to communicate with patients, 6 would use e-mail to provide additional information to patients and only 1 would use e-mail to schedule appointments or deliver test results. Among the 20 physicians who approved of their office staff using e-mail for patient communication, 70% believed that e-mail could function to schedule appointments and only 20% thought that office staff should use e-mail to give test results.

Confidentiality and safety are considerable concerns for physicians. Both GPs and SPs ranked their concern about confidentiality at 75 on a 100-point scale. GPs gave e-mail safety a median rank of 25, and SPs assigned a median rank of 30, where a score of 0 indicates no safety and 100 indicates confidence in safety. Eighty percent of physicians indicated that they believed that their workload would either increase or greatly increase if they were to communicate with their patients using e-mail.

DISCUSSION

Our survey shows that 57% to 66% of the parents interviewed have access to e-mail. This is similar to the published numbers for the United States.¹ E-mail access was related to the parent’s age, parent’s education level, and family income. The finding that income and education are primary factors in determining e-mail access is consistent with previous surveys.^1,2 Surprisingly, we did not find that younger parents are more likely to have access to e-mail. Rather, parents between 31 and 40 years of age were the most likely to have access to e-mail after adjusting for education and income. The deviation from the trend in increasing e-mail access with education among those parents who are presently attending college suggests the role of family income on access to e-mail.

One limitation of the study is the generalizability of the parent population found in these offices. The urban and suburban city setting of the pediatric health care system from which our sample was drawn lends itself to a highly diverse ethnic population, many with low annual incomes. Because each of these factors influences access to technology, our parent-based conclusions may be skewed slightly. Nonetheless, parents were highly in favor of some type of electronic communication with their physician offices. In addition, few physicians were sampled. The small sample size certainly limits the interpretation and widespread application of physician-based results.

Parents of children who have chronic illnesses might be more inclined to use the Internet for medical information. For that reason, we hypothesized that parents from SP offices might be more inclined to have e-mail access and desire to use e-mail for physician communication and compared responses of parents from GP and SP offices. We found no difference between these 2 groups in their access to e-mail or their desire to communicate electronically with their physicians. Parents at GP offices were more concerned about confidentiality.

Patients and their parents are becoming more Internet savvy; more than half of the parents we interviewed reported that they had used the Internet to get answers to health care questions (data not shown). Parents showed a strong interest in using e-mail for a broad range of purposes from scheduling appointments to discussing a child’s symptoms. In a similar vein, Neill et al¹³ found that 90% of patients who use e-mail to contact their physician send important and private medical information via this medium.

Although the majority of parents favor electronic communication with physicians, they are aware of potential problems with confidentiality and safety surrounding this medium. We speculate that the reason for their limited concern is that the patients are children. Conceivably, the respondents would be more concerned about safety and/or confidentiality if their own health issues were involved. Adolescents may also be more concerned about parents or other family members seeing physician-patient e-mail. We did not interview adolescent patients in our survey.

The majority of physicians in our survey have the hardware and software to communicate electronically. At this institution, a concerted effort was made to connect all full-time academic faculty to e-mail. This included all of the SPs interviewed and explains why SPs had a higher degree of e-mail capability than the GPs. The disparity between SP and GP access to and use of electronic communication indicates that this may be a point where education should be targeted. Although at the time of the survey 26% of GPs did not have Internet access at their offices, there has been a subsequent effort to ensure that GPs are also connected.

Although the physicians were generally opposed to answering patients’ e-mail inquiries themselves, the majority were responsive to the idea of having their office staff use e-mail for patient communication. Among physicians, concerns about confidentiality, time demands, and increase in workload motivated an opinion against electronic communication with patients. Borowitz and Wyatt¹⁴ reported on a subspecialty consultation service available via the Internet. Although they found that the time commitment was only approximately 4 minutes per day, this may not reflect the time commitment for physicians with established patient-physician relationships. These concerns are valid as there is potential for release of confidential information (accidental or intentional) and delays in treatment.⁸ To address some of these issues, guidelines for physician-patient electronic communication have been published.¹⁵

Although we found that a relatively small percentage of physicians were open to the use of e-mail communication, an e-health network survey of physician e-mail use with patients found that 10% of physicians interact with patients via e-mail at least 1 time a week.¹⁶ This percentage is a 200% increase in less than a year. Some systems are also beginning to reimburse physicians for their time spent in e-mail communications with patients.¹⁷

Many of the potential e-mail benefits identified in this survey involve the interaction of patients and office staff. Most physicians were more accepting of this use than they were for their own involvement. Although many published discussions of e-mail use include these roles, there are few published data on the attitudes of physicians or office staff. Patient e-mail communications directed through an office staff triage system could decrease the time demands on physicians while meeting most of the families’ desires. It would be important for patients to be aware that a staff member is screening their communications directed to the physician.

Several sociologic and legal factors will ultimately determine the future of physician-patient e-mail communication. Increasing access to e-mail and ongoing time constraints of the American population are factors that might prompt patients to demand this service. Case law will establish whether there is an increased or decreased malpractice liability through the implementation of electronic communication. Third-party payers must determine whether there will be compensation for physician time outside of the standard face-to-face encounter. Finally, the forthcoming Health Insurance Portability and Accountability Act regulations will define standards for privacy and security regarding medical information transmitted electronically. The unfolding of these issues will surely have an impact on the future of patient-physician relationships as the world becomes increasingly dependent on electronic communications.