"Email is the killer app of patient portals."
I heard a variation of that quote when interviewing people for the patient-provider communication chapter of the book I've been co-editing and writing for HIMSS with Jan Oldenburg, Brad Tritle and Kate Christensen. For the organizations who've pushed patient portals the furthest into their patient base, email is always the place where things started. In other words, email is the gateway drug for patient engagement which Leonard Kish called the blockbuster "drug" of the century.
Physicians are understandably concerned about being overwhelmed by emails if they provide an option for secure messaging. As healthcare transforms, financial incentives have a big effect on the willingness to take on what many perceive to be “more unpaid work” (forgetting the fact that playing voicemail tag is also unpaid). Interestingly, the physicians who have given out their phone number or enabled secure email (without remuneration) haven’t found they are overwhelmed by any means. In the case of the groundbreaking Open Notes study, many of the doctors just heard crickets. For those who have proactively enabled email communications, they have experienced a number of benefits. See the section below on improvements in outcomes simply by having email. [Disclosure: One of the capabilities included in the patient relationship management system my company provides is secure email.]
Dr. Ted Epperly has been a family doctor for decades and describes his experience as follows:
“I give them both my phone number and a way to contact me via email. In 32 years of being a family physician I have had this privilege abused less than 5 times. On the flip side it has led to many occasions where I have been able to expedite care and save countless number of office visits, ER visits and hospitalizations. That is patient-centered care and I personally feel better for it.”
Dr. Howard Luks is an orthopedic surgeon also has experienced similar benefits.
“Physicians underestimate the fact that opening up a digital channel to facilitate post visit, post-surgery, etc. comments and questions can and does provide a very real ROI if you dive into the typical workflow pattern that evolves when a patient calls with questions. If my assistant or nurse is tracking me down after fielding a phone call, they are not available to perform work that will lead to income. If I can answer a question with a brief email it saves everyone time and enables him or her to remain active in meaningful tasks. So... there are tangible reasons why the use of digital communications in this day and age are worthwhile, but many are not savvy enough to realize the upsides and fear that they will be inundated with an enormous number of useless emails. I can tell you that it never happens and patients start most every email with " sorry, but I ...". They are very respectful of the opportunity to engage in this format and they are very cognizant of the fact that it does take away from my other clinical related activities.
It is clear that providers can impact how their patients use secure messaging. Providers who suggest that their patients follow up digitally will introduce it with messages that state, “After you’ve taken these new medicines for a couple of weeks, please send me a secure message and tell me how you are doing.” They also advertise their willingness and ability to engage with patients via secure messaging knowing they will have more digital encounters than their counterparts who mention it rarely or not at all.
As providers do more of their visits via secure messaging, however, systems will need to think about new models for compensating providers that acknowledge writing a thoughtful message to a patient does take time and needs to be balanced with other work. Some organizations, such as Group Health, expect over a quarter of their doctors’ time will be spent responding to email. The most important driver is reimbursing on outcomes. When that happens, email simply becomes a tool like any other organization (outside healthcare) to enhance communication with their clientele.
Outcomes Improve with Secure Email
In a 2010 study done at Kaiser Permanente reported in Health Affairs of 35,423 people with diabetes, hypertension, or both, the use of secure patient-physician e-mail within a two-month period was associated with a statistically significant improvement in effectiveness of care as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). In addition, the use of e-mail was associated with an improvement of 2.0–6.5 percentage points in performance on other HEDIS measures such as glycemic (HbA1c), cholesterol, and blood pressure screening and control.
Recently published data by the Lund Report indicates that Kaiser patients enrolled in their patient portal, which includes secure messaging with doctors, access to clinical data, and self-service transactions, are 2.6 times more likely to stay with the organization than those who are do not participate online (see more on avoiding system leakage in ACOs here). Countries such as Denmark provide incentives for doctors to communicate electronically reported in a Commonwealth Fund report entitled Issues in International Health Policy. The result: 80% of physician/patient communication in Denmark is asynchronous (i.e., people talking to each other serially rather than simultaneously). At first, that can sound high until we think about the rest of our lives whether it is conducting business or communicating with friends, where asynchronous communications (e.g., such as email, voicemail, or texting) are the norm.
Email can be one way to address the problem that patients remember so little of what they are told in the provider’s office. Other options include providing a clinical summary to patients after the visit (as recommended by Meaningful Use measures) and providing documentation of a care plan online for patients to refer to later.
Screenshot of a patient portal sending an automated patient appointment reminder.
