Incentives needed for doctors to email

Even though patients are clamoring for it and health organizations see its benefits, electronic communication from primary care physicians won't become commonplace until doctors' workloads are reduced – or they get paid extra for emails and phone calls.

That's according to a new study from Weill Cornell Medical College, which examined six different medical practices that routinely use electronic communication for clinical purposes. The report appears in the August issue of Health Affairs.

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“Leaders of medical groups that use electronic communication find it to be efficient and effective – they say it improves patient satisfaction and saves time for patients," said Tara F. Bishop, MD, assistant professor in the Department of Public Health and Medicine at Weill Cornell Medical College, in a statement about the study results. "But many physicians say that while it may help patients, it is a challenge for them.

"The lack of compensation is one issue, and another is that unless the practice takes steps to reduce a physician's daily workload of patients, communicating with patients is extra work that makes some doctors feel that their day can never end."

Nonetheless, more physicians may soon find themselves compelled to communicate via patient portals or secure email as patients and practice management demand it.

"I think there are ways to make a transition to electronic communications in health care work," she said in the statement. "Our study offers some good examples, but I still think we have a long way to go before physicians routinely email their patients."

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Even as simple electronic messages have been shown to improve care and lower costs – such as emailing test results to patients or checking in on chronic conditions without the need for an office visit – very few physicians avail themselves of it.

By 2008, the latest year for which figures are available, fewer than 7 percent of doctors regularly communicated with their patients electronically, according to Weill Cornell researchers.

Seeking to know more about the practices that do embrace email, Bishop and her team interviewed leaders of 21 medical groups – and also spoke to staff, including physicians, in six groups that use electronic communications extensively, but varied in their approach.

Four of the medical groups had more than 500 physicians and one had 115 physicians. The sixth had 15 physicians within a large academic medical center. None were affiliated with Weill Cornell.

Among the researchers' findings:

All six practices used electronic means to communicate test results, allow patients to request medication refills, appointments and to ask questions of their doctors.

• Three practices used nurses, medical assistants or case managers to triage messages from patients. In the other three practices, patients could email nurses for refills or the front desk for appointments, but they could also email their physician directly.
• The volume of emails that reached physicians in the six programs varied from five to 50 each day.
• Only one clinic charged patients for what it referred to as "e-visits" – emails that involved clinical decision-making. This group negotiated reimbursement for e-visits with private insurers and patients paid a copayment.
• Another clinic imposed a $60 annual fee for unlimited electronic communication but later dropped the charge because competitors provided the service for free.
• Two medical groups added so-called "desktop Medicine time" to their physician's schedules, while another allowed providers to decide how many patients they would see each day, thus providing time for electronic communication.

Bishop said the advantages of electronic communication in these groups were obvious – and they outweighed the disadvantages for all parties involved.

"We were told that patients love this model," she said in the statement. "Leaders and frontline providers also said the system was efficient, safe and helped them provide high-quality care. Physicians also said it was an efficient form of communication for them."

That's not to say there were no disadvantages, however. The biggest one was that emailing means more work for providers.

"One leader said that the work never ends," added Bishop. "It takes a psychological toll on some people – the feeling of never being done. Another said that in one day, he sometimes sees 10 patients face-to-face but communicates with another 50, commenting that he works all the time."

While emailing does seem to reduce office visits for individual patients, many physicians do not have a decreased overall workload, she noted. Instead, their clinics simply send them additional patients to see.

One way to address that is to focus on team-based care that manages electronic communications and workload, Bishop suggested. Another would be to compensate physicians for electronic communication in ways other than traditional fee-for-service, which does not yet include payment for time spent on emails.

"One leader told us that insurance companies said that if physicians are doing it for free, why should we pay for it?" she said in the statement.

"Despite the fact that we found experiences with electronic communications were, on the whole, very positive in the groups we studied that have embraced this technology, we believe the big stumbling block to its widespread use around the country will be compensation," concluded Bishop. "Until different payment models emerge, electronic communication is unlikely to be widely adopted by physician practices."

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