Should doctors be paid to e-mail their patients?

by Michael Kirsch, MD

This is a less controversial issue than patients ‘friending’ their doctors on Facebook, which I oppose. Although most physicians’ offices are not e-mailing with patients, perhaps they should. There are several obvious advantages.

* Decompress phone lines, which are suffocating nearly every medical practice in America.

* Relieve patients of the cruel and unusual punishment of languishing on ‘hold’ listening to elevator music or dead air.

* Allow office staff to efficiently respond to patients’ cyber inquiries at scheduled times.

* Eliminate the need for the ubiquitous phone menu system, a torture chamber that tests the mettle of even the most robust and seasoned patients

* Facilitate documentation of patients’ inquiries, which is not reliably accomplished with phone calls.

* Permit staff and physicians to access patients’ e-mails from remote locations.

* Allow for e-mails to be forwarded to other staff and physicians with a keystroke.

* Available 24/7.

Sure, e-mail communications between physicians and patients makes great sense, but it costs doctors dollars. Should this be a free service? The current culture of medical practice in this country is not to charge a fee for patients’ phone calls. Like every doctor, I spend hours each week on the phone with patients. This is free medical care. Patients feel entitled to this pro bono service, as I do when I call my doctor or dentist.

But is this fair? If a patient calls me to ask a medical question, then why shouldn’t I be compensated for giving professional advice that requires medical training and experience? Is this free medical care a service that we should provide to our existing patients? What about patients whom we have never seen who call us after hours with a medical issue? Should this be a freebie also? Many phone calls morph into phone office visits, which not only are free, but also may not provide optimal care to the patient.

When I call my lawyer there’s always a ticking sound that I hear in the background. For lawyers and other professionals, phone calls are fair game. Ironically, while physicians don’t charge for phone calls, we are still legally liable for the medical advice that we offer during these gratis exchanges.

Will e-mails be the next generation of donated physician time? E-mails and phone calls to physicians should be reimbursed. Primarily, because it is fair to pay people for the work that they do. In addition, charging a fee would help reduce many of the unnecessary calls (or future e-mails) that deluge our office.

I welcome differing opinions on this issue. If I respond back, it will be free of charge.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • http://medrants.com db

    I have written recently that the insurance model is undesirable for primary care. Email is a big reason. When I have talked to retainer physicians, they do a large amount of email. Patients often love this type of contact. If we used a retainer fee model, then email would be included.

    Phone calls are similar. Many physicians dread phone calls, because we cannot bill for them.

    We must rethink our payment system to improve physician patient communication. Email is an obvious way to streamline physician patient communication.

    So I am a huge fan of email – but I would like to have a payment system that makes email and phone access a good deal for everyone.

  • http://www.preemieprimer.com Dr. Jen Gunter

    At Kaiser we e-mail our patient as part of our medical practice. It is encouraged in fact. When we open the email the patient’s entire electronic medical records it at our disposal making and we have time obviously to think about the appropriate response. Personally, I find it faster and easier than phone calls because I don’t have to go back and forthw ith the nurse trying to understand what the patient was really asking. Things do get lost in translation!

    Whether we should be paid is an entirely different matter. The problem is people are coming in less and less because of co-payment costs. They are rationing themselves already, so I suspect charging for e-mails might further limit access to doctors.

    It does bother me that lawyers get paid for everything (even licking the stamp), but I also accept that financial system is not part of medicine in North America.

  • pheski

    I’m a family physician. I do use e-mail with patients on a limited basis, although it is not sanctioned by my employer or supported by the eHR we use. (It could be.) I do so because it is a tool that can clearly enhance care when used properly.

    You left two extremely important benefits off your list: it also allows the patient to document the content of the call, and it allows me to include links to other resources.

    In terms of payment, I think the solution is obvious if not easy: stop paying providers piecework and pay us for the job in a more global sense. If I am being paid to provide a patient with quality care, I have an incentive to use whatever tools are most appropriate and most likely to efficiently provide the care. If I am paid a small amount for visits and a larger amount for procedures, we have escalating costs and quality is subservient to quantity. IMO.

  • W

    I had a surgeon who allowed e-mail communication. It has the advantages you mention, but since it requires less effort than going through the phone maze or scheduling an appointment, it’s also a surprisingly easy privilege to abuse with unnecessary interactions.

    One possible approach that seems reasonable to me: Offer the service for a fee, and make clear to the patient up front the advantages, disadvantages and parameters — who’s going to be reading e-mails, should replies be expected, will there be an auto-reply if you’re out of the office, in what circumstances e-mail should NOT be used, etc. Explain that there are other communication avenues available without any charge, such as the patient advisory nurse (if your clinic has one)…the e-mail service can be presented as an “a la carte” option.

    You can always choose later not to bill the patient for e-mail (if you wish) if s/he has stuck to the agreement and used the access sparingly. Those who e-mail often and with questionable need can and should be charged as you explained at the outset.

  • American Expat in Europe

    A continued thanks for your thought provoking blogs. I think doctors should absolutely be allowed to charge for phone consultations and subsequently e-mail. Living in Switzerland my GP charges for phone consultations near as I can tell. At least for me e-mails would be a lot more succinct, concise, and focused vs phone calls. And my guess would result in a lot less people showing up in the office. That said, to your point, there has to be a time limit on responses.

  • concerned, educated patient

    Doctors and patients alike should be concerned about the security of email. Unless both parties encrypt, email can be intercepted without much difficulty if it goes through the Internet (as most of it does these days). Check with your lawyers about HIPAA implications.

    I like the notion in general. My family doctor and I have a good relationship and we email occasionally. He gets free technology consulting from me, so I don’t feel like the exchange is unfair. But it does blur boundaries.

    PhD in MIS

  • Nuclear Fire

    Email is definitely something I would like to see incorporated into modern medical practice.

    In addition to the items mentioned above, there are two concerns I have. The first is the level of acceptable security that will be required. At this time in the US, it appears that the legal gurus are recommending that all email communications be via a secure portal. This adds a layer of significant expense to the interaction as well as removing the ubiquity and ease of the interaction. Given our medico-legal climate, I would like one of our techno savvy politicos to include into future legislation something allowing standard security such as on google to be acceptable.

    The second problem is the patient who emails a twelve page, 100 bullet-pointed diatribe. Although I don’t use email regularly in my practice now (exceptions made for my patients who are also physicians or medical students) I have had a few patients track down my unadvertised email and send me the above mentioned missives. I that case, I’ve called the patient, told them that it seems like they have many issues they want to discuss and that there is too much to deal with in email and if they’d like to discuss them I’d be happy to have them come in for an appointment.

  • http://promotehealthconsulting.com/blog Melissa Kennedy MD

    I’m a physician who has also recently been a patient with questions. From both perspectives, I love the idea of using email for quick and straightforward questions AND I hate the idea of charging per email. It feels very “nickel-and-dime-ish”. A better solution, as mentioned above, would be to look at email, like phone calls, as a part of the overall service we provide. This only works we are paid in a more global way for “taking care of a person,” at rates which take these other communications into consideration. I don’t think it would serve us well to move into the attorney’s model of billing everything by the minute.

    I have used email with patients (until my employer told me I had to stop so that they could make the patients come back for another billable visit). In that somewhat limited experience, I did not find that patients abused it. When I gave them my card with my email address, I mentioned that I was glad to answer emails about straightforward questions and that if they had more complex issues they would be better off making an appointment so we could discuss in detail.

  • Anonymous

    At this time in the US, it appears that the legal gurus are recommending that all email communications be via a secure portal.

    The reason is that most people using normal email do not encrypt it (or even know how to). So forcing users to send and read email through a web portal that forces encrypted communication with the browser is the usual way of ensuring that the communication does not go out unencrypted on the internet. On-line banking is similar in this respect — if you want to send email to the bank about your account and read the bank’s reply, you have to do it through the bank’s web portal.

  • jsmith

    We have secure portal email setup with the EHR at my clinic. I almost never use it because I have more important things to do. Also, if you send an email with lab results, then the pt will often email back a question. Email tag. Come on, folks, we’re docs, not computer-jockeys. Not a good use of our time. Google Ricardian comparative advantage if you don’t understand why.

  • MarylandMD

    Some friends we know in Leesburg, VA get charged something like $25 per call for after hours calls to their pediatric practice, and apparently a number of practices in that area are doing the same thing. I know after hours calls are different, but it is a sign that patients are in some cases being asked to take on the cost of care beyond the standard office visit.

    I want to get paid for calls that go beyond simple questions (“Which medication did you tell me to stop?”) and involve medical decision making. I have had patients who are clearly calling to avoid having to come in and pay a copay, and a few have even said as much. I have them make an appointment as I refuse to give extra care for free, although I don’t put it quite that way.

    I do not communicate via email as my employer does not sanction it due to security/privacy concerns. I would like to, but, again, I would want to be compensated for medical decision making. Otherwise, I would strictly limit email to very simple questions or clarification of my advice from a visit.

    We are getting nickel-and-dimed to death by the patients’ insurance companies. If the patients do not like paying for phone calls, they should ask their insurance companies to pay us more fairly for what we do. We should not protect patients from the real cost of extra care by giving things away for free. The more we do that, the less pressure there will be for the insurance companies to fix the problems with physician compensation.

  • Finn

    I can email my doctor through a secure portal and do so when I have a quick question (“New med makes me drowsy; can I take it at bedtime?”) or she’s asked me for an update. I know she’s insanely busy so I try very hard to make my emails as concise as possible, and only about something we’ve already discussed during an appointment.

    Email is, as mentioned, far less maddening and time-consuming than calling, what with the outgoing message telling patients what the office hours are and to hang up & call a different number if it’s after hours or this is an emergency, followed by several nested menus that I navigate through only to be tormented by muzak for various lengths of time before reaching the secretary who, if my call concerns anything other than appointment scheduling, puts me back into the muzak for even longer while she pages the nurse, who at some point (hopefully before the sun rises again) takes the call, listens to my question, promises to call me back, & hangs up–presumably to later put my question to my doctor. If I’m very, very lucky, she actually does call back before I descend into the subway at the end of the workday.

    By comparison, the 3-sentence email I send to my doctor takes perhaps a fifth of the time even if I spend 5 minutes editing it down to essentials, and I don’t have to worry about missing the nurse’s call-back later because I’m in the subway. Now, if I call the office it’s to say x, y, & z are going on, should I come in?

    I think doctors should be paid for emails and phone calls that involve medical decision-making, but I also think the current fee-for-service model–which covers neither–is destroying primary care. I’m not sure what the solution is, except that it probably involves prying the insurance company out from between doctor and patient.

  • AnnR

    The ideal thing would be similar to electronic tolls on a freeway.
    You ante up some amount of money, say $25-50 that’s covered by your flexible spending plan.

    Then you chip away at it by the message until you’re out of credit and it’s time to refill.

    With “free” phone calls you have to air your personal matter to some nurse or receptionist who, for all you know, blabs it to everyone around or gets your issue wrong. Then you’re stuck waiting for a phone call that may or may not arrive depending on when you called and whether the doc is too busy or can reach you. Of course, if he/she reaches you it’s almost always when everyone is there to listen in or the kids are screaming and it’s not the best time to talk.

    With a paid-for email you put your concern down and don’t press “send” until you thing you’ve got it laid out as clearly as you can. For your fee you should get some kind of turnaround – maybe 8-24 hours response. The message comes to you. You can go to the bathroom without worrying you’ll miss “the” call.

  • H

    Ultimately, communicating with patients cuts into profits no matter how you do it.

    As you doctors reject electronic communication, you will eventually have a whole generation of patients you won’t be able to communicate with.

  • Okulus

    H:

    At least the face-to-face communications start with the understanding that there is a service being paid for; with letters, phone calls and e-mail, that same time spent carries no such expectation. Big difference.

  • http://warmsocks.wordpress.com/ WarmSocks

    It would take less of my PCP’s staff’s time to read & respond to emails than it currently takes them to respond to phone inquiries.

    The current system requires a receptionist to answer the phone and interpret my question, then reduce it to written form. This takes time, paper, and ink. It takes even more time for the nurse to decipher the gist of my question and call back. Sometimes the conversation needs to be documented, which requires even more time.

    Email would require less/no time on the part of the receptionist, and take less time for the nurse than phone calls currently take. Email could require patients to be concise in their inquiries instead of rambling on about the weather, pets, etc. If a phone inquiry would result in “you need to come in” then email could just as easily say that in less time than a phone call. If documentation is required, it’s simple to retain the email.

    Phone calls aren’t as secure as some are making this sound. Numbers get misdialed. Answering machines permit anyone to overhear what is said. Most homes have multiple lines; anyone can pick up an extension and evesdrop. This is true in many workplaces, too. Privacy gets compromised over the phone. Privacy can be protected over the internet.

    I suspect that physicians would be surprised at the number of patients willing to pay cash for the convenience of email with their doctor’s office.

  • H

    “At least the face-to-face communications start with the understanding that there is a service being paid for”

    But procedures make even more money. Why talk when labs and tests are more profitable.

  • Okulus

    “But procedures make even more money. Why talk when labs and tests are more profitable.”

    Sometimes. Carriers are wise to testing; they limit payment if more than a certain number are ordered within a set period and also if the ICD code does not appear to justify the test ordered (in their estimation, which is suspect.)

    So many of the tests I order have nothing to do with whether I talk or not, and I don’t earn a penny extra for ordering them; they are done by outside laboratories and radiology centers. If anything, they are makework for me as I have to order screening labs for imaging and then have my staff do the pre-approval process which costs me time and money. Then of course, I have to follow up on them which involves phone calls or letters to the patient which is still more uncompensated time and money. I wish I could order less testing.

    Procedures? I do them, but again, unless it is something cosmetic, the time for money in the procedure along with the inclusive period–as long as 90 days–makes the doing of procedures in my specialty of debatable value. Of course, it is more valuable than doing nothing, but it isn’t necessarily more valuable than seeing more appointments in the office in the same amount of time spent in surgery and during followup visits..

  • will6

    Great question! I would welcome physicians who would communicate via email; there’s a better chance I’d get an answer during the day, especially when it involves adjusting a medication. Right now my pediatrician’s practice only returns calls of that nature between 1 and 2 p.m.; I have a feeling it would be faster for them if they could respond via email. I’d love to be able to also send along any information that I’ve uploaded into my HealthVault account that might offer insight into the issue, like a peak/flow test, etc. I want doctors to get reimbursed for their time. I also want to improve the communication so that we both spend as little time as needed to resolve an issue. If I can avoid bringing in my child, and thus avoid risk to exposure to some other virus, that’s great for everyone. Email shouldn’t be the only line of communication, but it sure can be a handy one.

  • Doc Stone

    Why such passivity about payment mechanisms. It sounds like the docs are taking no responsibility for their own professional lives. Only doctors, independently one at a time, can bring about a change in that. If you think a different payment arrangement will facilitate improvement of your care, you have an ethical obligation to adopt it. The success or failure of that in the marketplace will then inform us all of whether your patient’s share your perception of the service’s value.

  • http://drcisneros.com Jose A. Cisneros

    I believe that today, reading and answering emails is an important part of any job description. Doctors that email have better interactions and documentation that if they don´t.
    For patients, it is hard to understand how doctors, earning 3 times more than any other graduate professional, refuse to provide a service that improves communication. Most doctors hide behind answering machines and lack email contacts. Expecting to charge for emails and phone calls like lawyers, is probably not a very good idea, since we all know their reputation.
    Other incentives have to be implemented for doctors to use email to prescribe orders, lab results and important data, instead of calling you to tell you that everything is OK.
    A good patient-doctor relationship and communication is a paradigm in medicine, If a patient is your customer, you have to support him/her as best as you can, if it is too much work, then let´s create new jobs until the load is manageable, but the patient wellbeing and satisfaction should always be first.

  • Aestivate99

    I’m not a health care professional of any kind. I’m a customer/patient. I agree with Doc Stone – make it happen if you think it’s good. I dislike the comments that whine about lawyers getting paid for everything (“even licking the stamp”). What purpose does that serve? I am also not a lawyer. Great blog. Just discovered it today thanks to a Facebook friend posting.