Patients like it and so do health organizations, but electronic communications in clinical care will likely not be widely adopted by primary care physicians unless patient workloads are reduced or they are paid for the time they spend phoning and emailing patients, both during and after office hours.
Those are some key conclusions of an in-depth examination by investigators at Weill Cornell Medical College of six diverse medical practices that routinely use electronic communication for clinical purposes. The detailed report, the most comprehensive of its kind, appears in the August issue of the journal Health Affairs.
"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. But many physicians say that while it may help patients, it is a challenge for them," says the study's lead author, Dr. Tara F. Bishop, an assistant professor in the Department of Public Health and Medicine at Weill Cornell Medical College.
"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," she says.
Still, pressure from patients and from practice management may ultimately force physicians to communicate with their patients via electronic health records or secure email, Dr. Bishop adds. "I think there are ways to make a transition to electronic communications in health care work. Our study offers some good examples, but I still think we have a long way to go before physicians routinely email their patients."
Five-50 patient emails per doc per day
The push for electronic communications has been widely endorsed as a means to improve quality of care by, for example, emailing test results to patients, or managing clinical conditions without requiring a time-consuming and costly office visit. Still, few physicians use it. By 2008, the latest year for which figures are available, less than 7 percent of physicians regularly communicated with their patients electronically.
Dr. Bishop sought not to conduct a national survey of use of electronic communication in doctors' offices, but to investigate how different practices use it, how successful they are, and what barriers they face.
She and her team interviewed leaders of 21 medical groups, and also interviewed the health care staff, including physicians, in six groups that use electronic communications extensively, but varied in their approach. Five of the six medical groups were large— four 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.
The leaders said they started electronic communication programs to improve access to care and communication with their patients. All six practices used the program to communicate test results, to 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 daily.
Only one clinic charged patients for "e-visits"— email 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 "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.
"The work never ends."
The advantages of electronic communication in these groups were obvious and they outweighed the disadvantages, says Dr. Bishop. "We were told that patients love this model. 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."
The researchers found the primary disadvantage to using electronic communication is that it creates more work for providers. "One leader said that the work never ends. It takes a psychological toll on some people—the feeling of never being done," Dr. Bishop says. "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."
The researchers found that physician resistance to change and lack of payment are barriers to use of electronic communications. "One leader told us that insurance companies said that if physicians are doing it for free, why should we pay for it?" Dr. Bishops says.
While electronic communications does seem to reduce office visits for individual patients, many physicians do not have a decreased overall workload—their clinics send them additional patients to see, she adds.
She says these issues can be addressed by team-based care that manages electronic communications and workload, or by compensating physicians for electronic communication in ways other than traditional fee-for-service, which does not yet include payment for time spent on emails, Dr. Bishops says.
"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," Dr. Bishop concludes. "Until different payment models emerge, electronic communication is unlikely to be widely adopted by physician practices."
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