With the public’s increased use of the Internet, the use of email as a means of communication between patients and physicians will likely increase. Yet, despite evidence of increased interest by patients, email use by physicians for clinical care has been slow.
To examine the factors associated with physician-patient email, and report on the physicians’ adherence to recognized guidelines for email communication.
Cross-sectional survey (March–May, 2005) of all primary care physicians (n = 10253), and a 25% stratified, random sample of all ambulatory clinical specialists (n = 3954) in the state of Florida. Physicians were surveyed on email use with patients, adherence to recognized guidelines, and demographics.
The 4203 physicians completed the questionnaire (a 28.2% participation rate). Of these, 689 (16.6%) had personally used email to communicate with patients. Only 120 (2.9%) used email with patients frequently. In univariate analysis, email use correlated with physician age (decreased use: age > 61;
This large survey of physicians, practicing in ambulatory settings, shows only modest advances in the adoption of email communication, and little adherence to recognized guidelines for email correspondence. Further efforts are required to educate both patients and physicians on the advantages and limitations of email communication, and to remove fiscal and legal barriers to its adoption.
The Institute of Medicine’s vision for a high quality healthcare system includes the concept of patient-centeredness, which emphasizes the need to be responsive to patient preferences and needs [
The current literature on the subject of physician-patient email is generally focused on somewhat limited populations or attributes. Work has been done, for example, on the experiences of early physician [
To help interested doctors benefit from email communication with patients, the American Medical Association (AMA) and the American Medical Informatics Association (AMIA) have adopted sets of guidelines for physicians [
As part of a statewide study of information technology (IT) use in the ambulatory setting, we surveyed 14921 physicians in Florida, using the State Department of Health’s list of allopathic and osteopathic physicians with clear and active medical licenses. The survey (see
The survey and a cover letter were sent in March, 2005, to all primary care physicians (general internists, pediatricians, family physicians, general practitioners and obstetricians/gynecologists) and a 25% stratified random sample of other specialists. Due to the nature of the study, we excluded those with a practice address outside of Florida and those who do not traditionally practice in the ambulatory setting (eg, radiologists, pathologists, anesthesiologists and emergency physicians). Each questionnaire was tracked by a six digit identifying code. After four weeks, nonrespondents were mailed a second cover letter and questionnaire to reiterate our interest in their participation. Those physicians who indicated, by phone or mail, that they were no longer actively treating patients (ie, retirement, or other reasons) were excluded. Surveys returned after the initial mailing because of unknown or changed address were remailed when an updated address was obtained. Completed questionnaires were returned by physicians via business-reply paid postage. Data were entered into a computer database and subjected to verification and cross-check methodologies. For example, the first batch of entered data by each staff member was 100% verified to prevent data entry errors. Subsequently, a minimum of 10% of all surveys were verified. If problems were encountered in a batch, they were fixed and the proportion verified was increased. If any patterns of data entry errors were detected in a batch, verification of the field for all surveys was made. The protocol was approved by the institutional review board at Florida State University.
The survey included demographic questions which enabled us to identify differences in the use of email by practice size, medical training, practice type, age, race, and gender. To examine practice size, we computed categories based on number of physicians practicing at a given location. Medical training (or "specialty") refers the area in which respondents said they spend the majority of their practice time in (ie, internal medicine, family medicine, pediatrics, and so on). Age was categorized by decade and included those less than 40 years, those aged 41-50, 51-60, and 61 or older.
To analyze the data, we first employed standard descriptive statistics and utilized chi-square analysis or Fisher’s exact test (as appropriate) to identify significant differences among the independent variables of interest. Next, we utilized binary logistic regression models to compute adjusted odds ratios. In these models, independent and covariate predictors included medical training (primary care or other), practice size and type as well as physicians’ age, race, and gender. Our dependent variable was email use with patients. In addition, using a similar model, we examined whether or not any of the predictors independently was related to adherence to the 13 communication guideline items described above. For this analysis, we collapsed all the medical specialties into primary care or other. Primary care was defined as family medicine, internal medicine, and pediatrics. All analyses were computed in SPSS version 13.0 and two-tailed significance was considered at the
A total of 4203 returned surveys were available for the current study. This represents a 28.2% participation rate. Demographic and practice characteristics of the respondents are shown in
Demographic and practice characteristics of responding physicians
(n = 4203)
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Demographics of Respondents: | ||||
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Age: Mean (range) | 50.64 | (30–86) | ||
Gender: Male | 2479 | (75.9%) | ||
Race/Ethnicity | ||||
Caucasian | 2875 | (68.4%) | ||
Hispanic | 539 | (12.8%) | ||
Asian | 433 | (10.3%) | ||
African-American | 133 | (3.2%) | ||
Other (or unknown) | 223 | (5.3%) | ||
Practice Characteristics: | ||||
Mean years in current community | 14.4 | (< 1– 52) | ||
Mean years since medical school graduation (range) | 21.4 | (< 1– > 65) | ||
Specialty: |
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Family Medicine | 756 | (18.3%) | ||
Internal Medicine | 783 | (18.9%) | ||
Pediatrics | 602 | (14.6%) | ||
Obstetrics/Gynecology | 454 | (11.0%) | ||
General Surgery | 42 | (1.0%) | ||
Surgical Specialty | 393 | (9.5%) | ||
Medical Specialty | 709 | (17.1%) | ||
Other |
397 | (9.6%) | ||
Presence of an office computer | 4015 | (96.1%) | ||
Presence of Internet access | 3812 | (96.5%) | ||
High-speed access | 2848 | (85.3%) | ||
Dial-up connection only | 404 | (12.2%) |
*Based on majority time spent in practice as reported by respondents.
† Includes all other specialties, and physicians primarily in administrative roles.
Overall, 689 physicians (16.6%) indicated that they personally used email from their office to communicate with patients. A majority of these doctors reported doing so rarely (314; 45.6%) or occasionally (255; 37%), with only 120 (17.4%) physicians saying they frequently used email to communicate with their patients (at least once on half of all business days). These 120 doctors represented 2.9% of 4148 physicians who responded to the email question in the survey. Physicians who frequently sent email to patients did not differ demographically from those who sent email only rarely or occasionally, except, of note, all 120 physicians who stated they frequently emailed patients practiced in urban areas (
Using email to communicate with patients was first assessed by physician age, race, medical training, practice size, and to urban geographic practice location using univariate analysis (see
When analyzed in a multivariate model, only two variables were noted to be statistically significant predictors for email use. Physicians who practiced in groups of 50 or more were more likely than physicians in solo practice to communicate with patients via email (adjusted OR = 1.94; 95% CI = 1.01–3.79). In addition, Asian-American respondents appeared to use email communication less commonly with patients then Caucasian physicians (adjusted OR = 0.26; 95% CI = 0.139–0.487).
Number and percent of physicians who use email with patients in Florida (n = 689)
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689 | (16.6) | ||||
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Less than 40 years old | 79 | (16.4) | 1.00 | |||
41-50 years | 197 | (17.6) | 1.09 | (0.75–1.59) | ||
51-60 years | 168 | (18.2) | 1.23 | (0.83–1.81) | ||
61 years or older | 56 | (11.7) | .014 | 0.69 | (0.42–1.12) | |
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Male | 410 | (16.7) | 1.00 | |||
Female | 119 | (15.3) | .34 | 0.87 | (0.64–1.17) | |
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Caucasian non-Hispanic | 522 | (18.3) | 1.00 | |||
African-American or Black | 21 | (16.0) | 1.24 | (0.66–2.34) | ||
Hispanic | 78 | (14.6) | 0.82 | (0.57–1.16) | ||
Asian | 31 | (7.2) | 0.26 | (0.14–0.49) | ||
Other race or unknown | 37 | (17.7) | < .001 | 0.91 | (0.48–1.71) | |
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Family Medicine | 154 | (20.6) | .001 |
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Internal Medicine | 114 | (14.7) | .11 | |||
Pediatrics | 86 | (14.5) | .14 | |||
Obstetrics/Gynecology | 75 | (16.7) | .93 | |||
General Surgery | 7 | (16.7) | .98 | |||
Surgical Specialty | 83 | (21.4) | .007 | |||
Medical Specialty | 113 | (16.0) | .67 | |||
Other | 46 | (11.8) | .008 | |||
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Single specialty | 407 | (15.2) | 1.00 | |||
Multi specialty | 81 | (18.0) | .12 | 1.07 | (0.73–1.58) | |
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Solo practice | 176 | (14.5) | 1.00 | |||
2-9 physicians | 330 | (15.5) | 1.01 | (0.70 –1.32) | ||
10-49 physicians | 87 | (22.7) | 1.11 | (0.63–1.95) | ||
50 or more physicians | 56 | (27.3) | < .001 | 1.94 | (1.01–3.79) |
* Univariate
†
‡ In multivariate analysis, we compared primary care physicians to other specialists; adjusted OR = 0.97 (0.77–1.24).
Of all physicians who did not currently use email with their patients, 13.4% indicated a future interest in doing so. An additional 52.8% expressed no desire to begin using email with patients and about one-third (33.8%) were undecided about future email use with patients.
Of the 689 respondents who indicated using email with patients, only seven doctors (1.6%) indicated requiring their patients to abide by
Number and percent of selected email guideline items being adhered to by physician practices in Florida (n = 689)
Furthermore, only 46 physicians (6.7%) required their patients to comply with at least half (7) of the 13 guideline items (
Physicians’ self-reported adherence to recommended guideline items when emailing patients
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Print email communication and place in-patients’ charts | 331 | 48.0 |
Inform patients about privacy issues with respect to email | 250 | 36.3 |
When email messages become too lengthy, notify patients to come in to discuss or call them | 148 | 21.5 |
Establish a turnaround time for messages | 111 | 16.1 |
Request patients to put their names or identification numbers in the body of the message | 111 | 16.1 |
Send a new message to inform patient of completion of request | 111 | 16.1 |
Establish types of transactions | 110 | 16.0 |
Explain to patients that their message should be concise | 70 | 10.2 |
Remind patients when they do not adhere to guidelines | 55 | 8.0 |
Develop archival and retrieval mechanisms | 57 | 8.3 |
Instruct patients to put category of transaction in subject line of message | 48 | 7.0 |
Configure automatic reply to acknowledge receipt of patients’ messages | 42 | 6.1 |
Request patients to use auto-reply features to acknowledge clinician’s message | 28 | 4.1 |
Among the physician-respondents, 2593 (63%) indicated the use of email from their office for communication with groups other than patients. Most commonly, they reported the use of email to communicate with friends or family members (74.2%), other doctors (63.8%), and for business-related communications (50.1%). Less common (though still more common than email to patients) was email to hospitals (29.2%) and pharmaceutical companies (20.5%). Lastly, 12.9% of physicians suggested emailing some “other” group besides those listed above.
Patient-provider electronic mail has been previously defined as “computer-based communication between clinicians and patients within a contractual relationship in which the healthcare provider has taken on an explicit measure of responsibility for the client’s care” [
Yet, the present study, conducted in mid-2005, found that only 16.6% of physicians in Florida used email with patients, and only 2.9% of the overall respondents used it frequently. This latter number, derived from physicians’ responses, suggests how rare email communication remains in clinical practice and is substantiated by studies showing the low number of patients who have ever sent email to a physician [
These barriers have been identified previously [
The pace of email communication to patients has also been slowed by concerns from physicians [
There may be a difference in perceptions between patients and physicians of the benefits accrued from the use of electronically available information. For example, a survey of patient use of the Internet for health information suggested that patients perceive more benefits and fewer risks than their physicians do, when this mode of information gathering is utilized [
Another important observation from the current study is that the use of email with patients occurs most frequently among certain groups of physicians. In one of the few studies that reported demographic information of physicians who do, and do not, regularly email patients, Gaster et al found that female physicians, younger physicians, and university-based clinic physicians were proportionately more likely to use patient email [
As email communication differs from traditional, written medical communication between physicians and patients and among providers, guidelines for best practices have been developed. These guidelines have emanated from both the medical [
One of the most important findings of the current study is that few physicians were routinely utilizing these guidelines for email communication with patients, despite their broad availability for several years. In this regard, the current study results are similar to those of Gaster and colleagues from a 2000-2001 survey of physician practices related to email use [
The low rate of adherence to published physician-patient email guidelines may have several reasons. Among these reasons may be the lack of knowledge about the existence of guidelines by many practicing physicians; the lack of agreement with the guidelines (eg, not feeling that the guidelines are required in their particular practice), or an impracticality to their implementation. Unfortunately, the present study was not designed to determine reasons for not adhering to these recommended guidelines. However, given the results presented in the current study, the medical profession should consider further educating physicians about email communication, assess the barriers facing implementation, and better understand the practicality of utilizing the guidelines themselves.
We acknowledge that there are several important limitations of this study. First, we recognize that the survey response rate, although higher than comparable previous studies [
To enhance email communication between physicians and patients, we believe that further work to educate both physicians and patients on the advantages and limitations of email correspondence is necessary. In addition, efforts are needed to deal with the fiscal barriers many physicians face in the regular use of email as a quality-enhancing tool in patient care. Although we are encouraged by recent efforts to reimburse physicians for email communication in several areas of the United States, most US physicians do not yet have access to these reimbursement programs. As these barriers are addressed in the United States, we believe email communication between physicians and patients will become better defined, better compensated and a resource for better clinical care of patients.
Funded in part by the Center for Medicare and Medicaid Services, Department of Health and Human Services, under contract number 500-02 FL02.
None declared.
Survey of Physician Information Technology use in Florida, developed by the
Florida State University College of Medicine.