August 3, 2008

Doctor Use of Patient E-Mail Still Low Despite Benefits

By Rick Stouffer, The Pittsburgh Tribune-Review

Aug. 3--Ten years ago, Dr. Jeff Cohen had to make a move.

With a burgeoning local urology practice, Cohen's time was being swallowed not by what he enjoyed -- treating patients -- but by ancillary duties; specifically, making, taking and returning patient telephone calls.

"The problem is getting two people in the same place at the same time for a phone call," Cohen said. "It's annoying, and it destroys the relationship with the patient."

Cohen's solution was to turn to technology that 10 years ago was a communications standard in nearly all other industries: e-mail.

"We tell all our patients, 'don't call -- send us an e-mail,'" Cohen said. "In 10 years, I've only had one patient upset."

E-mail communication makes sense in an industry where time between physician and patient is divided into 15-minute appointments, while medical records available at the touch of a computer key are becoming the norm.

But potential legal problems, adapting to something that changes a practice's workflow, the expense of installing a secure, encrypted system -- even the possible loss of practice revenue -- have slowed physician adoption of high-tech correspondence, experts said.

Cohen and fellow partners at Triangle Urological Group's use of e-mail to communicate with patients isn't unique, but it's certainly in the minority among physicians nationwide.

A survey conducted this year by research firm Manhattan Research of New York found that about 36 percent of U.S. physicians are communicating with patients via e-mail, instant messaging or secure messaging services.

According to the Center for Health System Change, in 2004-2005 just 24 percent of the country's doctors were using e-mail to communicate with patients, up just 4 percentage points from the center's 2000-2001 survey.

Given that other surveys estimate that more than 70 percent of America has Internet access, and that 90 percent of all patients would like to communicate via e-mail with their doctors, what's the holdup?

"One major drawback why physicians aren't using e-mail is they don't know the legal ramifications," said Mike McCann, a Vermont Law School professor and a visiting professor at the Boston College Law School.

McCann said there's a large body of case law in place concerning personal interaction or telephone communication between physician and patient when disputes arise, but not with e-mail correspondence.

"How a word is said is obvious with a face-to-face meeting or via a phone call, but that's lost with e-mail," McCann said.

HIPAA, the Health Insurance Portability and Accountability Act of 1996, requires "electronic protected health information," including e-mail, be communicated securely, or encrypted. Encryption, depending on system sophistication and whether it meshes with other electronic systems in an office, for example, can be expensive.

"We've spent hundreds of thousands of dollars on our system, with encryption and computers, but I absolutely would recommend it," Cohen said. "Once through the investment phase, it cuts costs. We used to have four transcriptionists; now, we have one -- part-time."

"Getting to Jeff's office is strenuous," said Cohen patient William Fazi, of Washington, near Apollo, Armstrong County, "I'm the sole proprietor of my electronics repair business, so if I have to go to Pittsburgh, I have to shut the business."

Fazi said e-mailing eliminates the long waits to get to the office for news of a procedure or test. "E-mail is quick and to the point. I don't have to wait for a visit, wondering."

Lack of privacy when using e-mail is a big concern to doctors, but not so much to most patients, experts said. "Patients just don't seem too concerned by a pack of privacy when using e-mail, perhaps they're just not aware that regular e-mail isn't protected," said Dr. Gary Fischer, associate professor of medicine at the University of Pittsburgh.

Three of the University of Pittsburgh Medical Center's primary care physician practices, and about 7,000 of their patients use a secure Web site portal for correspondence.

Fischer added that another doctor worry concerning e-mail is that patients may think e-mails are answered as soon as they're sent, and thus may e-mail when a phone call or even a visit is required.

Shadyside plastic surgeon Jay McCafferty is a firm believer in using e-mail to correspond with patients, both current and potential.

"Some 70 percent of our e-mail correspondence is with patients we haven't yet seen," McCafferty said. "It also helps with potential patients who are out of town, even out of the country. They can get information, ask questions, plus it frees staff time so they can take time with patients already in the office."

Some e-mail proponents said it is perfect for such tasks as scheduling appointments, giving test results, or clarifying physician advice. E-mail creates a written record that either electronically is placed in a patient's record, or is printed, then placed in a file.

"For patient follow-ups, using e-mail sure beats having to come back to the office," said Darlene Kauffman, associate director of payer relations for the Pennsylvania Medical Society. "E-mail is so well-liked by patients that it could be used as a marketing tool by physicians."

In theory, e-mail is supposed to reduce the number of phone calls and faxes from patients, but implementation, even excluding cost, can be difficult, some industry watchers said.

"In theory, e-mail could reduce the number of phone calls, but it still must be integrated into the practice's workflow," said Joy Grossman, senior researcher with the Center for Health System Change in Washington, D.C. "It adds another place for doctors to look for information."

Still, backers insist the spread of e-mail is inevitable. "There are barriers to e-mail usage, but they will be overcome," Fischer said. "It's inevitable it will be used -- every other industry does it."


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