Patient-Doctor E-mail Could Impact Income for Physician Practices

In a very interesting study, researchers at Kaiser Permanente in the US found that patients who consult their physicians via e-mail are less likely to visit their physician or to call their doctor's office and as a result could reduce income for physicians whose revenue is generated by direct face-to-face contact. This study presents observations in a US context, however the findings also deserve examination and discussion from a Canadian perspective.

I have used non-secure e-mail to communicate with patients in my practice for the past 4 years. With clear guidelines on use (printed on the back of appointment cards) and on the practice web site, the number of e-mails received has certainly not been overwhelming and in many cases, it is simply a request for an appointment, an e-mail to cancel an existing appointment or a a request for medication renewal. Secure e-mail is the next level up and moves the clinical encounter into a virtual space. However, communicating via e-mail is time consuming and takes time away from direct patient encounters. As a result, without a clear mechanism to reimburse physicians who provide consultation services to patients for secure e-mail interaction, the same is likely to be seen in Canada in fee-for-service practices.

In alternative-payment models of practice e.g. salary or blended models (non fee-for-service), secure e-mail makes perfect sense. If patients can be kept out of the practice (for minor conditions), e-mail is likely to reduce the workload for physicians and staff. However this is only in situations where the physician is reimbursed to provide care for a patient population whether or not that patient is seen face-to-face.

The other issue in Canada is the physician resource crisis. There are a significant number of patients who cannot find a family doctor and are instead dependent on walk-in clinics, urgent care centres or emergency departments for their primary care. If it were possible to reimburse family physicians for providing a certain amount of care via secure e-mail, it may increase capacity in medical practices in order to absorb some of the orphan patients who receive their care from multiple providers in a very episodic fashion. 

"Article: Patients who consult with their physicians via e-mail are less likely to visit their physician and less likely to call their doctor's office, according to data from the Kaiser Permanente Center for Health Research, the Portland Business Journal reports. Kaiser found a decline of between 7% and 10% in primary care office visits for patients who e-mail their physicians and a 14% decrease in patient phone calls to doctors' offices. The reduced number of office visits could help save money for employers and insurers, although it also could be financially harmful for medical practices that rely on patient visits for income from insurance reimbursements, the Journal reports.

Kaiser Northwest several years ago began using e-mail as part of a pilot project, and currently, 113,000 Kaiser members in Oregon and Washington state use the Internet and e-mail services as part of their health plan. Patients are becoming increasingly interested in secure e-mail services, and they might pressure clinics to invest in the systems or develop a new business model to pay for the systems, according to the Journal (Moody, Portland Business Journal, 6/29).

Link: E-mail good for patients, not so much for docs - Portland Business Journal (Subscription required for full article access)

What do you think? Is secure e-mail communication with patients a valuable service in Canada? What needs to be put into place in order to make secure e-mail viable and useful in a Canadian setting? To share your thoughts and experiences, please click on the 'Comments' link.

Comments

[Dr. J. Fernandes]

The concern about Physician incomes being decreased because of email Physician support is unsupported. Physician email support to patients is potentially a very useful and fulfilling service on both the part of the Physician and on part of the patient.

Patients in my practice follow specific guidelines in regard to email support. For several patients that are deaf or blind, email support is vital to their ability to access the office. For other patients that travel extensively, email support offers a great deal of reassurance when things go awry overseas or in the U.S. (where they often access "medical care" from a paramedic that set up shop in a shopping mall inside a pharmacy).

Email support is an uninsured medical service in Canada, and Canadian Physicians are therefore able to charge for it. A reasonable annual fee for email support to patients under a mutually agreed upon contract can actually give the Canadian Medical Practice a sorely needed financial boost!

Physicians that lose office income as a result of providing email support to their patients, simply choose to experience the loss of income.

For example: 1000 patients each paying $100 for email support can easily offset increasing office overhead costs and stagnant insured fee increases.

[Alan Brookstone]

The following is an excerpt from an article published in the National Review of Medicine on the use of e-mail by physicians.

"In our increasingly globalized and electronic 21st-century economy, why have doctors been so slow to adopt email?

According to Dr Danny Sands, a Harvard University and Cisco Systems medical informatics researcher and Boston-area internist, many physicians worry that emailing patients will take hours out of their days. "Email seems like it could be disruptive if you haven't done it," he explains. But he has done it — since 1991 — and he's found it anything but disruptive.

"The reality is it takes a lot less time to communicate by email," says Dr Sands, comparing it to many kinds of office visits. And he has found that patients rarely abuse the privilege by bombarding him with emails. He admits it does happen occasionally: one patient's constant messages and stubborn refusal to just come into the office led to an email "pissing match," says Dr Sands, that only ended when she left his practice. But after 16 years of emailing with patients, Dr Sands has developed a rough guideline to estimate how many emails you might receive: for every 100 patients, you can expect to get about one email per day. "Doctors have to get over this fear of technology," he says. "Email will make patients happier and doctors happier." Link: NRM Practice Management: Your patients: You've got mail!."

[Yves Raymond]

Income plays no part in my dislike of e-mails

You have to be very careful with e-mail. Any communications expert will tell you that e-mail is not a very rich medium. In fact, writing is one of the poorest mediums to convey information in a precise way. I personnaly draw a lot when speaking to patients to help them understand their illness

On e-mail, patients are unable to hear the tone of your voice, the look of sympathy on your face etc...Furthermore, e-mail can be used in court, and can be open to interpretation by your patients and their lawyers. Unless you are very confident that what you write is exactly what you mean and that it cannot be misinterpreted, then go ahead.

Be aware though that patients can misinterpret what you write and that lawyers may have a field day with your punctuation and poor sentence structure. I would limit it to basic administrative type e-mails for now. ie appointments etc...

[Adam Chen]

Use of email in clinical medicine is a fine example of how a new tool can either help or hinder, depending on how we use it.

During our past 2 years of EMR I used it extensively, for 1) emailing patient education material, eliminating my large inventory of paper handouts; 2) emailing Antenatal Record Questionnaire, and eventually Physical Questionnaire, so there would be no waiting for patients to complete forms when they arrive for the visit, 3) Instructions about how to locate a specialist with a shorter waiting time, 4) List of referrals such as physio/massage/optometry/chiropractic, 5) Quick FYI's such as when patient has to check on a detail about family history or medication and get back to me, saving reception from relaying message.

Eventually I'd like to set up a system where we can notify English as a Second Language patients of referral information, to save time on the phone for our reception. Of course there will be a system in place to ensure message is received.

So far many patients knows my email address, but none have misused it to cause me grief.

Curiously, for a few years when we carried a pager for 2500 patients, when patients could reach us directly (without screening from an anwering service), we did not experience abuse from any patients.

Perhaps it all depends on factors other than the tools themselves.