The Myth of Doctors Getting Overwhelmed by E-mail

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”Email is the killer app of patient portals.”

I heard a variation of that quote when interviewing people for the patient-provider communication chapter of the book I co-wrote (HIMSS 2014 Book of the Year –Engage! Transforming Healthcare Through Digital Patient Engagement). For the organizations who’ve pushed patient portals the furthest into their patient base, email has always been the foundation. In other words, email is the gateway drug for patient engagement which Leonard Kish called the blockbuster “drug” of the century.

Physicians are understandably concerned about being overwhelmed by emails if they provide an option for secure messaging. As healthcare transforms, financial incentives have a big effect on the willingness to take on what many perceive to be “more unpaid work” (forgetting the fact that playing voicemail tag is also unpaid and frustratingly inefficient). Interestingly, the physicians who have given out their phone number or enabled secure email (without remuneration) haven’t found they are overwhelmed by any means. In the case of the groundbreaking Open Notes study, many of the doctors just heard crickets.

A recent addition the Open Notes initiative was Kaiser. When they instituted Open Notes, traffic to their portal increased 400% yet the volume of e-mail traffic to doctors was flat. For those who have proactively enabled email communications, they have experienced a number of benefits. See the section below on improvements in outcomes simply by having email. [Disclosure: One of the capabilities included in the patient relationship management system my company provides is secure email.]

Dr. Ted Epperly has been a family doctor for decades and describes his experience as follows:

“I give them both my phone number and a way to contact me via email. In over 30 years of being a physician I have had this privilege abused less than 5 times. On the flip side it has led to many occasions where I have been able to expedite care and save countless number of office visits, ER visits and hospitalizations. That is patient-centered care and I personally feel better for it.”

Dr. Howard Luks is an orthopedic surgeon also has experienced similar benefits.

“Physicians underestimate the fact that opening up a digital channel to facilitate post visit, post-surgery, etc. comments and questions can and does provide a very real ROI if you dive into the typical workflow pattern that evolves when a patient calls with questions. If my assistant or nurse is tracking me down after fielding a phone call, they are not available to perform work that will lead to income. If I can answer a question with a brief email it saves everyone time and enables him or her to remain active in meaningful tasks. So… there are tangible reasons why the use of digital communications in this day and age are worthwhile, but many are not savvy enough to realize the upsides and fear that they will be inundated with an enormous number of useless emails. I can tell you that it never happens and patients start most every email with ” sorry, but I …”. They are very respectful of the opportunity to engage in this format and they are very cognizant of the fact that it does take away from my other clinical related activities.

It is clear that physicians can impact how their patients use secure messaging. Physicians who suggest that their patients follow up digitally will introduce it with messages that state, “After you’ve taken these new medicines for a couple of weeks, please send me a secure message and tell me how you are doing.” They also advertise their willingness and ability to engage with patients via secure messaging knowing they will have more digital encounters than their counterparts who mention it rarely or not at all.

As physicians do more of their visits via secure messaging, however, systems will need to think about new models for compensating providers that acknowledge writing a thoughtful message to a patient does take time and needs to be balanced with other work. Some organizations, such as Group Health, expect over a quarter of their doctors’ time will be spent responding to email. The most important driver is reimbursing on outcomes. When that happens, email simply becomes a tool like any other organization (outside healthcare) to enhance communication with their clientele.

Secure Email Improves Outcomes

In a 2010 study done at Kaiser Permanente reported in Health Affairs of 35,423 people with diabetes, hypertension, or both, the use of secure patient-physician e-mail within a two-month period was associated with a statistically significant improvement in effectiveness of care as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). In addition, the use of e-mail was associated with an improvement of 2.0–6.5 percentage points in performance on other HEDIS measures such as glycemic (HbA1c), cholesterol, and blood pressure screening and control.

The Lund Report indicates that Kaiser patients enrolled in their patient portal, which includes secure messaging with doctors, access to clinical data, and self-service transactions, are 2.6 times more likely to stay with the organization than those who are do not participate online (see more on avoiding system leakage in ACOs hereand the business case for patient engagement). Countries such as Denmark provide incentives for doctors to communicate electronically reported in a Commonwealth Fund report entitled Issues in International Health Policy. The result: 80% of physician/patient communication in Denmark is asynchronous (i.e., people talking to each other serially rather than simultaneously). At first, that can sound high until we think about the rest of our lives whether it is conducting business or communicating with friends, where asynchronous communications (e.g., such as email, voicemail, or texting) are the norm.

Email can be one way to address the problem that patients remember so little of what they are told in the provider’s office. Modern healthcare systems are using patient relationship management systems that include the ability to Flip the Clinic visit frequently built on top of a messaging system. Other options include providing a clinical summary to patients after the visit (as recommended by Meaningful Use measures) and providing documentation of a care plan online for patients to refer to later.

Skepticism Persists in Some Circles

Despite what I outlined above, we hear all the time from doctors who think e-mail would be a pain in the neck, and refuse to do it, and worry about liability, etc., Some also believe that most of the doctors who are in favor of it, work in larger practices or hospital-related practices, so there’s a lot of back-up staff and support to help out with things. I’d ask doctors who read this to share whether they believe that is the case.

Independent of the workload implications, I’ve yet to meet the doctor who isn’t passionate about improving outcomes. In a follow-on piece, I’ll outline how doctors are seeing how they can improve outcomes and the overall experience of their patients using simple, ubiquitous secure email.

David Chase is the CEO of Avado, a provider of secure communication tools for healthcare providers.

18 replies »

  1. docs do get that they are in the healing business, but docs do not control the purse strings, systems work for the corporations, the insurers work for the cooperations. the doc is the only one that has the patients best interest at heart. it is the reason that the terms population health and replaced personal health.

  2. I agree. Tell us what you would do. Do you really want outcomes? Or qalys? Most of the criticism in your citation has to do with motivating people: to stop smoking, to keep water and air clean, to exercise…et al. Maybe people really do not want outcomes, but rather lazing about smoking pot and going skiing. We can’t force people and many outcomes appear to need forcing too. I’m mainly trying to keep my telomeres long and my stem cells mitosing.

  3. I used FACS in the 90s, so yes. I’m aware. My point is that there’s plenty of chemistry, but no enough understanding of what works in care delivery and engagement. We’ve been delivering care for a long time, but very little attention is paid to what’s the best way to keep people healthy or to help them stay healthy or follow care adequately. For that matter, clinical care only makes up 20% of outcomes, so we’re focused on the wrong things if outcomes are what we’re after: http://medcitynews.com/2014/10/14-patient-barriers-may-delay-prevent-recovery/

  4. Leonard, There is more science than you see, but I get your point. Deep down, medicine and healthcare is just chemistry. Do you know what a fluorescence activated cell sorter is? Or a LC-MS/MS machine is? These are just lab instruments that are used to diagnose and treat lymphomas and leukemias. And for research. Many hospitals use them…or have them available. The science is just beginning. Nearly every drug has an astonishingly long chemical history.

  5. yeah, they value it RIGHT UP TO THE SECOND IT INCONVENIENCES THEM – as in, prevents them from getting info they need about their condition/test/treatment protocol quickly and easily, preferably without the hassle of a face-to-face interchange for information they “forgot”, or was too complex to absorb during their visit, etc

    self-reporting is always suspect, and especially so with respect to “privacy” – a concept most people have a tenuous grasp on (me included)

  6. a) physician services aren’t a commodity
    b) don’t be fooled by consultants’ hourly billing model. They “give away” plenty of information in the attempt to engage (and keep engaged) their clients and prospects.

    but forget all that elementary stuff: why is it that doctors do not get that if you’re in the healing business, an EXCHANGE of information is going to be much more valuable than whatever big-brained notes you file away for billing purposes (cynical old Dr Mike notwithstanding; he should just leave the profession because he is clearly not suited to it)?

  7. Philip – The “fix” I’ve seen on the reimbursement side is the shift from FFS to fee-for-value (typically in the form of capitation, monthly membership fees, etc.). Once you remove the distortions of requiring face-to-face interactions and other piece-part medicine, it’s natural for clinicians to use whatever the most effective communication tool is — whether it’s email, face-to-face, video interaction, etc. Having spoken with hundreds of doctors over the last few years, most say that 2/3 of their appointments aren’t necessary as face-to-face but that’s the only way they get paid — who can blame them.

    On your last question, many industries have off-loaded work to consumers and the consumers have been happy about that. Booking & checking in for flights is a simple example of that. It’s easy to imagine many healthcare examples of that. In addition, a modern tool should be able to delegate certain messages away from a doctor to another staff member or even an automated solution.

  8. Very interesting read.

    As, Mike WB mentioned before, one of the drawbacks is that the physician must invest his own time to support email communications. What % of physicians do you currently see adopting email communications with patients?

    Also, do you see a fix being on the reimbursement side? Or do you see a way where we can reduce the burden on the physicians (automated messages or questionnaires as an example)?

  9. This reminds me of so many things that physicians take on faith as true, even though they are based on pure assumption.

    I don’t necessarily argue with the internet being the blockbuster drug, but I haven’t seen any evidence that an internet connection improves outcomes, but maybe that’s true as well. Like a phone, the internet doesn’t do any good if there’s nobody to contact (or trusted info to receive), it has to be made relevant, credible, accessible and timely.

    In such a science-based field, it’s still unfathomable to me that there is so little science in actual care delivery, and engagement. We need a new science, as I said in the original blockbuster article. These things must be measured before assumptions are made.

    From misdiagnosis to our ever-obvious lack of understanding of nutrition (actually moving from almost polar opposites from decade to decade: carbs, cholesterol, margarine) it still comes down to this: we tend to get right what we’re paid to get right.

    I suspect we need a new internet-based approach to finding truth now that we’re (presumably) moving toward paying for actual outcomes.

  10. “Dr. Luks lays out how expensive the current processes are for doctors. We simply take those tremendous inefficiencies for granted”

    In many practices, depending on demographics, e-mail doesn’t replace any of those processes, it is just added on to them. One more place docs and staff need to remember to check for messages on a regular basis.

  11. there was a recent post about what patients valued most. it was privacy. So the whole secure email concerns me. Ask sony.

  12. Sure. There’s an entire best-selling entire book written on that topic. See http://en.wikipedia.org/wiki/Free:_The_Future_of_a_Radical_Price. Healthcare itself gives away lots of free things including free pharma samples, free ability to trade voicemails with a doctor, etc. While I 100% agree that payment reform is the central issue, Dr. Luks lays out how expensive the current processes are for doctors. We simply take those tremendous inefficiencies for granted. Even before payment reform (which I’m a vocal advocate for), there is still an ROI. I don’t think many people believe that an email is a substitute for an encounter with their doctor. Rather, it’s all the other rigamarole (scheduling, getting test results that are “OK”, etc. that waste the doctor’s time as well as their office) that could be done much more easily with simple, secure email. I’m certainly not suggesting that an appointment shouldn’t get compensated directly (e.g., telehealth payment) or indirectly (e.g., part of a capitated model). That is a separate issue from quick emails that could save a lot of hassle.

  13. can someone give me an example of an industry that gives away their comodity for free? other then the free bisquit i occasionally get at chic fila, i cant think of any.

  14. When society has chosen to use a third party to make decisions about how much and whether I get paid for the services I provide, then I don’t see the point of these discussions. The patient doesn’t pay my bills, the chart note I generate does. In the case of employed physicians, the contract is with the employer, not with the individual doc, so I suppose the one writing the checks can tell the employee that email is part of the job. Or not. I guess that is why so many want to see docs employed.
    You may not like the cynicism, but I have seen over and over that patients rarely chose loyalty to their physician over who their insurance tells them to see. You know you really can’t have it both ways – the Marcus Welby types don’t much exist in a world in which the docs only get paid based on how much verbiage the EHR generates. If you want Marcus Welby, well, never mind, you’ve made your decision already now, haven’t you?

  15. John – You are correct that email has the potential to mismanagement. I like to have this link in my email footer as a guideline for myself and others — http://emailcharter.org/. I also think that “emailing your doctor” in many cases means “emailing your doctor’s office”. A modern email management system should have the ability to have some workflow rules, delegation, etc. so doctors’ time can be spent on the highest and best use. There is also plenty of times when asynchronous should shift to synchronous (phone, video or in-person). Email is just one tool — appropriate for many, but not all, uses.

  16. Is the email to be included in the EHR? How do the attorneys feel about this? Asynchronous email is sort of a pain. This is like talking to a customer tech at Comcast using text messaging…back and forth. Is there a nicer way to do this?
    Do you want patient spouses,etc.do be able to participate? Are they going to be burdened with screen names, passwords? Do you need real time access to the EHR to be able to do a good job with emails to patients? Does this preclude your doing this away from the office or at home?

  17. As a salaried HMO physician I get approx. 150 e-mails a week, occasionally approaching 40 in one day. Some e-mails can be taken care of quickly, some not so much. Even optimistically allowing 2+ minutes to answer each one (including read e-mail, review chart, reply), that’s up to another hour a day tacked on to the end of a long 10+ hour day. I much appreciate the usefulness of e-mail communications. But we were originally told that e-mails would substitute for in-person appts (you remember: the “medical home” model), then it changed to “in addition to.”

  18. I think the Internet is probably the blockbuster “drug” of the century, not e-mail, but I get Leonard’s point – and yours

    As the commenter in the post above suggests, I think selectivity is the key.

    An organization that doesn’t know how to handle e-mail or train employees to use e-mail properly – rather than be abused by it – is asking for serious trouble ..

    There are too many stories of people sitting at the dinner table answering e-mails from their bosses while children scream and spouses fume –

    I know you’ve been around the tech industry for a long time Dave, perhaps at some point you could share some of your personal guidelines on e-mail management