Use of Email to Communicate with Patients

I have recently presented a number of sessions for physicians on the use of patient portals and personal health records in order to more effectively engage patients in managing their own care. There is a great deal of evidence that providing patients with access to their medical information promotes better care and is associated with improved outcomes. So why are we not all doing this in our practices? The simple (and practical) truth is that there are still a number of barriers to simply making these tools available. The tools are not ready for seamless integration and physicians are also anxious that they would create an administrative headache for practices and potentially negatively impact patients.

However, the following study provides strong evidence that the anxieties and concerns may be unwarranted. An October 2, 2012, article published in Annals of Internal Medicine by principle investigators Jan Walker, RN, MBA and Tom Delbanco, MD titled “Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead,” examined the interaction between primary care physicians and their patients after providing access to clinical notes via a patient portal and electronic messaging. The study involved 105 primary care physicians and 13,564 patients at three institutions: Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington. An earlier article was published in December 2011.

Findings were based on patient and physician post-intervention surveys:

86% of patients with visit notes available opened at least one note and 5,391 patients who opened at least one note completed a post-intervention survey:

• 77% to 87% across the three sites reported that open notes helped them feel more in control of their care.
• 60% to 78% of those taking medications reported increased medication adherence.
• 26% to 36% had privacy concerns.
• 1% to 8% reported that the notes caused confusion, worry, or offence.
• 20% to 42% reported sharing notes with others.
• The volume of electronic messages from patients did not change.

After the intervention:

• 0% to 5% of doctors reported longer visits or more time addressing patients’ questions outside of visits (0% to 8%).
• 3% to 36% of doctors reported changing documentation content.
• 0% to 21% reported taking more time writing notes.

At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop. 59% to 62% of patients believed that they should be able to add comments to a doctor’s note and one in three patients believed that they should be able to approve the note’s contents. This was met by resistance, as 85% to 96% of doctors did not agree.

A number of years ago, I implemented an email policy in my practice and shared my regular (non-secure) email address via the practice website and appointment cards. My patients never abused the email address and during a busy week I may have received 4–5 emails. What helped was printing the email on the back of the appointment cards as well as publishing it prominently on the medical practice website.

An example of the (appointment card) email policy is provided below:

 

If you have any thoughts or comments regarding communication with patients via email, patient portals, or personal health records, please click on the “Comments” link below.

Comments

[T. Chang]

A shared care plan that resides within the EMR would be helpful, for example, as a patient portal to help engage the patient. We log phone calls (content)in our EMR as telephone visits for documentation purposes but we do not use email as currently this function would reside outside of our EMR and it would be cumbersome to cut and paste the email threads into the EMR.

[Alan Brookstone]

Terry, good point. Creating a comprehensive record requires some system to keep track of email messages, either creating pdfs and attaching to the record or copying and pasting. As we see more of the comprehensive functionality become available, there is a need to integrate it more effectively into the EMR. A shared care record is what we need to aim for with appropriate patients, but there are challenges if clinicians are using different EMRs.