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Recent evidence indicates increased access to and use of Internet and non-healthcare-related email by older patients. Because email adoption could potentially reduce some of the disparities faced by this age group, there is a need to understand factors determining older patients’ enthusiasm to use email to communicate with their physicians. Electronic mail (email) represents a means of communication that, coupled with face-to-face communication, could enhance quality of care for older patients.
Test a model to determine factors associated with older patients’ enthusiasm to use email to communicate with their physicians.
We conducted a secondary data analysis of survey data collected in 2003 for two large, longitudinal, randomized controlled trials. Logistic-regression models were used to model the dichotomous outcome of patient enthusiasm for using email to communicate with their physicians. Explanatory variables included demographic characteristics, health status, use of email with people other than their physician, characteristics of the physician-patient relationship, and physician enthusiasm to use email with patients.
Participants included a pooled sample of 4059 patients over 65 years of age and their respective physicians (n = 181) from community-based practices in Southern California. Although only 52 (1.3%) patient respondents reported that they communicated with their physician by email, about half (49.3%) expressed enthusiasm about the possibility of using it. Odds of being enthusiastic decreased with increased age (by 0.97 for each year over 66) but were significantly higher in African Americans (OR = 2.1, CI = 1.42 - 3.06), Hispanics (OR = 1.6, CI = 1.26 - 2.14) and men (OR = 1.3, CI = 1.1 - 1.5).
A perception of better communication skills of their physician, lower quality of interaction with physician in traditional face-to-face encounters, and physician enthusiasm to use email with patients were significantly associated with an enthusiasm to use email. Patients who did not use email at all were less enthusiastic compared to those who used email for other reasons. Half of the physician respondents were not enthusiastic about communicating with patients using email.
Despite perceived barriers such as limited access to the Internet, older patients seem to want to use email to communicate with their physicians.
Good communication between patients and physicians is a cornerstone of modern, high quality health care. Recent advances in communication technology are generating a variety of communication exchanges that could complement or replace more traditional face-to-face visits and telephone calls.
Because of its pervasiveness and relative ease of use, electronic mail (email) offers a potentially valuable resource for augmenting and improving communication between physicians and patients [
Despite effective doctor-patient communication being paramount for patients over 65 years of age [
While older patients may have more barriers that limit their use of the Internet, there exist several reasons why they could be enthusiastic about using email with their physicians. For example, traditional face-to-face communication encounters between older patients and their physicians may be ineffective if the discussions do not raise all issues of concern. Moreover, physicians are often less responsive to the psychosocial issues raised during visits by older patients than to similar concerns of younger patients [
Recent evidence indicates increased access to and use of Internet and non-healthcare-related email by older patients [
We hypothesized that, in addition to demographics and familiarity with technology, older patients’ enthusiasm to use email to communicate with their physicians would depend on their health needs and the quality of their relationships. Specifically, patients with greater medical needs and a stronger relationship with their physicians will be more enthusiastic about using email as a communication tool. Our main study objective was to test a model to determine factors associated with older patients’ enthusiasm to use email with their physicians. Secondarily, we examined factors associated with physicians’ enthusiasm to communicate with their patients using email.
We conducted a secondary data analysis of survey data collected for two large randomized controlled trials in Southern California, known as Communication in Medical Care 2 and 3 (CMC 2 and 3), which were designed to study and improve physician-patient communication regarding cancer screening. (See Fox et al [
CMC 2 was a community-based, longitudinal, randomized controlled trial conducted between 1998 and 2003 that involved 111 primary care physicians practicing full time in community-based office practices in Los Angeles County. Patients were recruited from these physicians’ practices. The patients were non-institutionalized and between 50 and 80 years of age; were physically and mentally capable of completing a 30-minute interview; and did not have a history of breast, cervical, colorectal, or prostate cancer. Only patients aged 65 - 80 were included in this analysis. Baseline and exit data were collected in 2000 and 2003 through 20-minute telephone interviews with physicians and 30-minute telephone interviews with patients. Data were collected on the patients’ health care access and utilization; general demographics; mental and physical health; patterns of physician-patient communication, including use of, and enthusiasm for, using email; and certain characteristics of patient-physician relationships. Survey-response rate for participants, after being enrolled, was 72%.
CMC 3 was focused on patients aged 65 - 79. Their 80 primary care physicians practiced in community-based practices in Southern California (excluding Los Angeles County). Baseline and exit data were collected in 2003 and 2006 through 20-minute telephone interviews with physicians and 30-minute telephone interviews with patients. A total of 5978 patients participated in both the original studies. Overall, the CMC 2 sample of patients from Los Angeles County represented a range of socioeconomic levels and was more diverse in its ethnic representation, whereas the CMC 3 sample represented more suburban areas, was predominantly white, and had somewhat higher socioeconomic levels. Over 11,000 people were contacted for recruitment over the telephone in 2003, from whom we obtained 3188 completed interviews for analysis.
To allow cross-sectional analyses for our main study objective of determining the factors associated with older patients’ enthusiasm to use email with their physicians, we pooled data from CMC 2 exit surveys and the CMC 3 baseline survey in 2003.
The study population of patients was limited to those over 65 years of age in 2003. For patients from the CMC 2 survey, age was determined by adding 3 years to the patient’s age in the CMC 2 baseline survey conducted in 2000. For patients from the CMC 3 survey, we used their age at the time of the CMC 3 baseline survey. The proportions of patients and physicians who used or were enthusiastic about using email as a communication tool were calculated from the pooled 2003 data.
Potential determinants of older patients’ enthusiasm to use email communication with their physicians
We first used univariate analysis to identify potential explanatory variables of enthusiasm for both patients and physicians using variables collected in both surveys. Chi-square analysis was used to compare the categorical variables, and the
Potential determinants of physician enthusiasm to use email communication with their patients
there was enthusiasm to use email by patients and physicians. For the cross-sectional analysis of patient enthusiasm, we conducted the logistic regression using generalized estimating equations (GEE) methodology. To account for potential correlations among patients with the same physician, patients were nested within their own physician.
For the cross-sectional analyses, we studied survey responses of 4059 patients over 65 years of age to evaluate the determinants of their enthusiasm to use email with their health care providers.
Characteristics of patients over age 65 in the pooled sample from the 2003 CMC 2 exit questionnaire and 2003 CMC 3 baseline questionnaire
Characteristic | Number of patients |
% |
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(73.1) | (4.1) | |||
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66 - 69 | 949 | 23.4 | |||
70 - 74 | 1557 | 38.4 | |||
75 - 79 | 1366 | 33.7 | |||
80 and older | 187 | 4.6 | |||
|
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Male | 1671 | 41.2 | |||
Female | 2388 | 58.8 | |||
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Non-Hispanic white | 3271 | 81.1 | |||
African American | 155 | 3.8 | |||
Asian/Other | 128 | 3.2 | |||
Hispanic | 479 | 11.9 | |||
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Married or living as married | 2496 | 61.6 | |||
Not married | 1556 | 38.4 | |||
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Has medical insurance | 3985 | 98.2 | |||
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Patient’s rating of his/her own health (n = 4050) | |||||
Fair, poor | 974 | 24.1 | |||
Good | 1301 | 32.1 | |||
Very good | 1321 | 32.6 | |||
Excellent | 454 | 11.2 | |||
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Patient (n = 4059) | 1456 | 35.9 | |||
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(7.8) | (6.4) | |||
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Patient thinks physician is respectful (n = 3458) | |||||
Never, sometimes | 82 | 2.4 | |||
Usually | 223 | 6.5 | |||
Always | 3153 | 91.2 | |||
Patient thinks physician allows enough time to talk (n = 4047) | |||||
Never, sometimes | 466 | 11.5 | |||
Usually | 1074 | 26.5 | |||
Always | 2507 | 62 | |||
|
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Importance of good communication skills of primary care provider (n = 4033) | |||||
Somewhat important | 126 | 3.1 | |||
Very important | 1730 | 42.9 | |||
Extremely important | 1384 | 34.3 | |||
More important than anything else | 793 | 19.7 | |||
Patient’s rating of provider’s communication skills (n = 4047) | |||||
Fair, good | 447 | 11.1 | |||
Very good | 1003 | 24.8 | |||
Excellent | 1600 | 39.5 | |||
Better than most | 997 | 24.6 |
aA patient was defined as having insurance if he or she indicated that they had Medi-Cal, Medicare, government or military insurance, or private insurance.
Few patients (1.3%) indicated that they communicated with their physician through email. Of patients who did not use email to communicate with their physicians, half (49.3%) reported they were enthusiastic about doing so.
Logistic regression analysis of patient enthusiasm to use email in 2003 (all patient characteristics were significant in univariate analysis)
Patient Characteristics | Odds Ratio | 95% Confidence Interval |
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0.97 | 0.95 - 0.99 | < .001 | |
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African American | 2.08 | 1.42 - 3.06 | < .001 | |
Hispanic | 1.64 | 1.26 - 2.14 | < .001 | |
Asian | 1.35 | .87 - 2.09 | .18 | |
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Male | 1.25 | 1.06 - 1.47 | .01 | |
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Married | 1.08 | 0.89 - 1.31 | .45 | |
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Fair or poor | 0.83 | 0.63 - 1.10 | .19 | |
Good | 0.95 | 0.74 - 1.24 | .72 | |
Very good | 0.99 | 0.76 - 1.30 | .95 | |
|
1.00 | 1.00 - 1.02 | .11 | |
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Do not use email for other purposes | 0.17 | 0.15 - 0.20 | <.001 | |
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Somewhat important | 0.84 | 0.51 - 1.38 | .49 | |
Very important | 0.92 | 0.77 - 1.12 | .41 | |
Extremely important | 1.01 | 0.82 - 1.24 | .91 | |
|
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Better than most | 1.58 | 1.17 - 2.14 | .01 | |
Excellent | 1.36 | 1.05 - 1.76 | .02 | |
Very good | 1.20 | 0.92 - 1.57 | .18 | |
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Never | 1.14 | 0.85 - 1.51 | .39 | |
Usually | 1.43 | 1.20 - 1.72 | <.001 | |
|
1.31 | 1.11 - 1.54 | .001 | |
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CMC 2 exit survey | 1.27 | 1.03 - 1.57 | .03 |
The regression model found several physician and patient-physician relationship characteristics to be significant. First, patients whose physician was enthusiastic about using email were 1.3 times more likely to be enthusiastic than patients whose physician was not enthusiastic. Second, patients who rated their physician’s communication skills high (better than most) were 1.58 times more likely to be enthusiastic compared to those who rated their physician’s communication skills fair/good. Finally, patients whose physicians
Regarding physicians’ enthusiasm to use email (
Characteristics of 181 physicians in the pooled sample from the 2003 CMC 2 exit and 2003 CMC 3 baseline surveys
Physician Characteristic (n = 181) | n |
% |
|
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(49.4) | (9.0) | |
|
(38.8) | (15.9) | |
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(12.4) | (8.5) | |
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< 40 | 51 | 28.2 | |
40 - 49 | 48 | 26.5 | |
50 - 54 | 38 | 21.0 | |
55 and older | 44 | 24.3 | |
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Male | 136 | 75.1 | |
Female | 45 | 24.9 | |
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Non-Hispanic white | 93 | 51.4 | |
African American, other | 12 | 6.6 | |
Asian/Pacific Islander | 40 | 22.1 | |
Hispanic | 36 | 19.9 | |
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United States | 100 | 55.3 | |
Mexico, Central America, South America | 19 | 10.5 | |
Asia, India | 35 | 19.3 | |
Other | 27 | 14.9 | |
Private solo practice | 97 | 53.6 | |
Private group practice | 49 | 27.1 | |
HMO, other | 35 | 19.3 | |
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Family practice/general practice | 96 | 53.0 | |
Internal medicine | 85 | 47.0 | |
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Physician | 137 | 75.7 |
Logistic regression analysis of physician enthusiasm to use email in 2003 (all physician characteristics were significant in univariate analysis)
Physician Characteristics | Odds Ratio | 95% Confidence Interval |
|
|
|
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40 - 49 | 0.92 | 0.31 - 2.73 | .88 | |
50 - 54 | 1.05 | 0.32 - 3.49 | .94 | |
55 and older | 0.84 | 0.24 - 2.98 | .79 | |
African American | 1.18 | 0.23 - 6.15 | .85 | |
Hispanic | 2.46 | 0.84 - 7.17 | .10 | |
Asian | 2.29 | 0.80 - 6.52 | .12 | |
Female | 0.37 | 0.14 - 1.00 | .05 | |
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25 or more years | 1.31 | 0.47 - 3.63 | .60 | |
5 - 9 | 1.87 | 0.55 - 6.41 | .32 | |
10 - 19 | 2.39 | 0.78 - 7.29 | .13 | |
20 or more | 0.94 | 0.26 - 3.38 | .92 | |
Private group practice | 1.62 | 0.65 - 4.05 | .31 | |
HMO or other | 0.78 | 0.25 - 2.43 | .66 | |
Family practice | 1.79 | 0.57 - 5.68 | .32 | |
General internal medicine | 2.11 | 0.47 - 9.54 | .33 | |
Do not use email for other purposes | 0.62 | 0.26 - 1.50 | .29 | |
Better than most | 1.09 | 0.39 - 3.03 | .87 | |
Excellent | 0.71 | 0.28 - 1.81 | .47 | |
Fair or good | 1.52 | 0.42 - 5.46 | .52 | |
Most important | 1.15 | 0.54 - 2.43 | .73 | |
Somewhat or very dissatisfied | 4.96 | 1.48 - 16.68 | .01 | |
Somewhat satisfied | 2.21 | 0.98 - 5.01 | .06 | |
Always | 0.28 | 0.08 - 0.99 | .05 | |
Never or sometimes | 0.79 | 0.33 - 1.90 | .60 | |
Always | 0.83 | 0.37 - 1.88 | .66 | |
Never or sometimes | 0.45 | 0.10 - 2.04 | .30 | |
Always | 2.22 | 0.93 - 5.28 | .07 | |
Never or sometimes | 0.35 | 0.10 - 1.19 | .09 | |
CMC 2 exit survey | 1.43 | 0.49 - 4.21 | .51 |
Electronic communication holds the potential to enhance the patient-physician relationship and quality of care by expanding the opportunities for patients and physicians to interact [
First, even though overall use of email with health care providers was low, older patients and especially non-whites were likely to adopt this technology if given the opportunity. Our findings strongly suggest consideration of email as a medium to overcome communication barriers affecting this population. Public interest in and demand for expanding the use of this technology in the senior population [
Second, our study suggests that the patient-physician relationship is relevant in determining patient enthusiasm to use email with a physician. Our study supports findings from a recent study which found that certain aspects of the patient-provider relationship affected interest in the use of computerized patient portals [
Third, we noted two unexpected findings related to demographics. First, subjects with self-reported poor health status were not highly enthusiastic about using email, contrary to findings reported in previous literature [
Adoption by older patients of email as a tool to communicate with their physicians might also depend on the attitudes and beliefs of physicians and the value they place on communicating electronically. Previous work shows the criteria applied by physicians to use email remain subjective and depend on factors besides patient barriers (eg, a patient’s access to the Internet), such as reimbursement for time spent writing email [
Our findings also have implications for strategies to improve the use of email by older patients and their physicians. Availability of the Internet through community resources and efforts to engage family members in the process could significantly affect the use of email by older patients whose access to technology may be limited. Physician enthusiasm could be increased by having continuing medical education programs on electronic communication with a focus on specific barriers noted by physicians (eg, HIPAA limits).
Our study has certain limitations. Our analysis was based on a cross-sectional secondary look at existing data, and data on certain factors that could have played a role in determining enthusiasm (eg, use of email by other family members, reimbursement to physicians) were not collected at the outset. Secondly, while patient enthusiasm may be higher now than it was in 2003, factors determining patient enthusiasm are likely not to have changed dramatically. Our strengths include a large sample size drawn from a large, populous area; a diverse population that is representative of the region; and the inclusion of both genders. We also have a wide representation of primary care with diverse sets of physicians.
In conclusion, our study lends support to our hypothesis that, in addition to factors related to patient demographics and familiarity with technology, enthusiasm to use email depends upon the quality of existing relationships between patients and physicians. We found that older patients, especially non-whites, are highly likely to adopt this technology, but that factors arising from their interactions with physicians in traditional face-to-face encounters or their physician’s interest in the use of email could adversely affect their interest. Significant opportunities exist to use electronic tools to overcome some communication barriers affecting older patients. Further study on whether the adoption of email can reduce communication-related health disparities in the older non-white population is warranted. Public interest and demand in expanding the use of email could potentially lead to changes in reimbursement policies concerning the use of email.
The study was supported by a grant from the National Cancer Institute (NCI RO1CA74322) and in part by the Houston VA HSR&D Center of Excellence (HFP90-020). These sources had no role in study design or execution, collection of data, writing the manuscript, or the decision to submit the manuscript for publication. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
None declared.
communication in medical care
generalized estimating equations
Health Insurance Portability and Accountability Act