The future of patient-doctor emails

There continues to be a push for more docs to answer patients’ emails.  And not get paid for it.  The only way this will work is in a direct pay model where doctors are paid on a monthly basis and no insurance company is involved.  American Medical News discussed how more patients not only want to email their doctors but want a quick response as well.

  • Surveys have found that a large majority of patients are interested in online communication with their physicians. But other studies have found that patient satisfaction rates could take a significant dive if the messages aren’t responded to in an appropriate period of time.
  • For a report in the April-June issue of Quality Management in Health Care, Mayo Clinic researchers analyzed 323 messages randomly selected from 7,322 collected for the study. They found that nearly all messages sent Monday through Friday were opened within 12 hours. But on the weekend, 87.1% of messages weren’t opened in at least 36 hours.
  • There is no evidence that negative consequences or outcomes are associated with longer delays, Rohrer said. But researchers want to study further whether there should be a standard for how responses should be sent, and how delays in response times affect patient satisfaction and health care decision-making.
  • Other surveys have found a correlation between patient satisfaction and message response times. A 2003 survey of patients using an online messaging service at the University of California, Davis, Medical Centers’ primary care network found that all patients who received a response right away were “very satisfied.” The rate of those who were “very satisfied” dropped to 73.8% when a response didn’t come until the next day. The more the response time increased, the more satisfaction decreased.

Welcome to the future of patient emails.

Here is what I see happening:

  1. You won’t be paid for it.
  2. You will be dinged if your response time is slow.
  3. You could be sued if your response is slow
  4. You are liable if you wrongly make a diagnosis to a cryptic message.
  5. You will lose money because answering patient emails makes them NOT come in to the office.

When you have only 500-700 patients, like Josh at Atlas.MD, then it easier to answer these emails and since you are being paid, you don’t feel abused by it.

And, by the way, I get billed for every email I send to my lawyer at $300 an hour.

Doug Farrago is a family physician who blogs at Authentic Medicine.

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  • Dike Drummond MD

    The traditional office visit is the most inefficient way to deal with a significant percentage of medical complaints for both the patient AND the doctor. It is focused only on the needs of the physician and completely ignores the preferences of the patient. Come on in so I can take a look (because otherwise I won’t get paid)

    It is amazing to see what happens within practices that disconnect office visits from compensation (Concierge for example) OR where email and other electronic ways to address patient concerns are actually paid for (Kaiser’s model I believe) … talk about creativity.

    Just think back to your last week in practice. What percentage of your patient visits could have been managed by a phone call, email, Skype Video Visit or some method other than having them drive in, park, get out, register and see you in the office. Not uncommon to notice that number is north of 25%.

    Our patients want options. These new ways of connection can be triaged, systemized and run safely and effectively. I predict they will be adopted within days of compensation formulas changing to reimburse for them … even in the most old school of organizations.

    Dike Drummond MD
    over 117 ways to Prevent Physician Burnout in the MATRIX report

    • Dr. Josh, AtlasMD

      I couldn’t agree more. That’s why out insurance free practice is happy to care for patients by phone, email, SMS and more.

      • Simon Sikorski MD

        Well said, but I’ve seen some insurance based practices in New York get compensated for keeping patients connected. Insurance companies are now looking into population management tools… and there are some pretty amazing wireless technologies that assist with that. Remote patient monitoring is just as essential as remote communications.

    • southerndoc1

      “I predict they will be adopted within days of compensation formulas changing to reimburse for them”
      Isn’t the point that, as we’ve been using e-mail for two decades and insurers still aren’t paying for them, it’s unlikely that they ever will? Instead, the expectation will increase, as the OP says, that this is just something else that doctors will do for no payment.

      • Dike Drummond MD

        My understanding is that Kaiser now expects their docs to do 25% of their patient care electronically without an office visit. I also heard (grapevine stuff, this) that they give you time and compensate for it. Now Kaiser takes global risk … so this makes sense.

        I believe ACO’s will move to a more flexible model of care delivery that includes email and such as they take more risk simply because an office visit is the most expensive way to do anything … it is all about providing the best care at the lowest price and Skype will do a lot.

        And don’t chime in about liability issues for electronic visits because THAT is a black box.

        Dike Drummond MD

  • Ron Smith

    I’m afraid you’ve got this all wrong. I’ve been answering emails since 2010. I’ve got a very, very efficient office with incentivized staff and nurse practitioners. And I’m solo and I’m loving it! Practice life is much better because I answer patients emails. It absolutely has not affected office visits or practice profitability. In fact, our practice is growing steadily and consistently month by month since 2010.

    We are also highly vested in the cutting edge technology. I’m a professional database programmer as well as a full time practicing Pediatrician. The comments about how high tech our office is has patients clamoring to join the practice. Email is considered one of the greatest pluses by our patients. Long ago I integrated images captured through all our iphones directly into my custom practice management and emr solution into the patient’s exam record. I am currently in an alpha testing for some new hardware that will let us do even more imaging with our iPhones.

    The comments are incredible. Patients see the high tech side of medicine in their primary care physician’s office and I can say unequivocally that it is a plus. Email is the foundation of any such technology.

    Our stated goal in the office is that ‘we like you and your children, but if you don’t need to be here in the office then we don’t want you here.’ The value of email is that it adds the ability for patients to send me pictures as well as text. If what I see or hear concerns me then I log in to my software wherever I am (even with my wife driving us down the interstate!) and check the child’s mexican record. If I need to talk to them, then I click one button and the software dials via the internet using Skype and in seconds I’m talking to the patient. If they need a prescription, I go again to the software, create the prescription, click one button and the prescription is faxed within a couple of minutes to their pharmacy of choice.

    If they need to come in to the office, then I’ll tell them. They already trust me so they know that I wouldn’t tell them that unless it was in their best interest. If I think they need to be seen seen before then, I’ll send them to the ER.

    Believe me, patients know they don’t want to go to the ER if they don’t have to. That’s the expertise that are looking for from me.

    I will take email any day over a page. Email gives me back control of my life that paging and returning phone calls takes away. My patients know I answer emails, and my email address and those of our mid-level providers and key office staff are posted clearly front and center.

    No, I’m not getting a fee for answering an email, but I never have been paid for a phone call either. The returns are measure in the success and profitability of the practice and the satisfaction of my patients, my staff, and me. More importantly I think it gives me a great tool to take better care of my patients.

    I long for the day when I will permanently dump my after hours phone call service. And that may not be so very much longer!

    Ron Smith, MD
    Pediatrics since 1983
    www (dot) ronsmithmd (dot) com

    • disqus_f4OBIScMpr

      “If what I see or hear concerns me then I log in to my software wherever I am (even with my wife driving us down the interstate!) and check the child’s mexican record.”

      And what are you going to so when autocorrect makes an equally egregious mistake as that, but one which actually negatively impacts one of your patients’ health?

      Tell the victim’s malpractice attorney to sue Apple?

      • disqus_f4OBIScMpr

        “If they need a prescription, I go again to the software, create the prescription, click one button and the prescription is faxed within a couple of minutes to their pharmacy of choice.”

        Hopefully if WILL be to the pharmacy they and you intended, and not a mexican one.

      • Ron Smith

        I think you’re overplaying that concern. I do my email work on my computer, not on iOS. I will check mail with my IOS and read it. But my responses are in a regular email application.

        To be honest, I can get to the root of the problem much quicker with email because I can reread their emails and give better consideration to the answer.

        The other thing is there are not uncommonly a couple of email volleys back and forth. These are usually short and help clarify my understanding.

        The concern you state about malpractice is way overblown. Email is email…a method of communicating. Its not the medium that puts you at malpractice risk…its the content of your communication. How you communicate responses to a patient gets much better over time. The word ‘probably’ gets used more and more even though you may respond with 99% certainty in your head.

        I suggest you try it if you haven’t. You can always stop using email. But I will tell you that all my Pediatric parents are well versed in what my four and three year olds call ‘digital media.’ Patients know and believe in high technology. And they judge your competency on it, rightly or wrongly.

      • EE Smith

        Having disabled “auto-correct” in frustration the second week I had my iPad, I had to laugh at that one! My other problem was a colleague named Rafe, whom auto-correct kept wanting to re-name “Rage”.

  • David Voran

    Change the payment scheme and suddenly asynchronous communication becomes profitable. But even in the old Fee-For-Service world secure e-mail communications are much more profitable than phone messages any day. The average phone call is a little over 2 minutes in length whereas the average e-mail communication a fraction of that (well under a minute). Secondly, and most importantly, the patient does half of the documentation and your response is automatically recorded in the chart along with the patient’s message.

    In our clinic the connected patients have reduced the time spent on the phone with patients by nearly 8 hours per nurse per week.

    Contrary to expectations recent studies have shown that connected patients actually come to the office more than those who are disconnected so it’s a good practice to connect in any medium favored by your patients, even in a fee-for-service world.

    Even 20 years ago when working in a paper-based system with campus-wide e-mail we used to print off the e-mail thread and include it in the paper chart and have the patient sign their messages when they did come to the office.

    We’re now participating in 2 at-risk ACO plans and electronic communications, home monitoring and a variety of tools we couldn’t afford to use before now become even more important as the more we see and do to our patients the less we get paid in the long run. The main thing is that frequent patient “touches” do help maintain quality indicators without all of the in-office and hospital procedures that in the past were pure revenue generators but now are critically evaluated and only performed if they are going to improve the patient’s status.

    As bandwidth expands we’ll probably be doing many in-house visits virtually and be expected to be available 24×7. Thanks to technology and physician extenders we’ll be able to be there when the patient needs us rather than when it’s convenient for us.

  • Simon Sikorski MD

    Great post Doug! There are quite a few organizations that have the e-medicine platforms available and doctors are getting paid for each email they send. Telemedicine is also a great way especially if your office is in a rural or hard-to-get-to location.

    I’ve seen some amazing technologies being unveiled at our Healthcare PIoneers events. Come check it out Doug. I’d love yours and other practicing physicians’ feedback on them.

  • anon3

    You wouldn’t like email, as it would involve answering a question directly, indeed at all, your umms and aahhhs and false accusations of mental illness would be there in black and white making you look stupid, as would your failures, for which you would not otherwise have evidence to prove when you fail in the usual way which is verbally with inadequate notes taken so no evidence at all

  • Kara

    It is imperative for medical groups to establish guidelines prior to implementing electronic doctor-patient communications. My primary care physician encouraged e-mail communications (to an unsecured e-mail address — and no legal disclaimers) for three years before I agreed. He either did not respond; was slow in responding or his response was a cut and paste from the Internet. The experience was extremely frustrating. I am in the process of finding a more responsible healthcare provider.

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