In a recent JAMIA (Journal of the American Medical Informatics Association) paper, investigators from the Indianapolis-based Regenstrief Institute took a close look at e-communication between patients and doctors, as well as the need to modernize guidelines.
Specifically, researchers noted that while patient-provider electronic communication has proliferated in recent years, there is still a “dearth of published research either leading to, or including, recommendations that improve clinical care and prevent unintended negative consequences.” As such, Joy L. Lee, Ph.D., Regenstrief Institute investigator, Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, and her colleagues took to understanding how existing guidelines align with current practice, evidence, and technology. For the research, investigators defined “electronic communication” as the direct exchange of text information using computers, Internet-enabled telephones, or other electronic devices between patients and healthcare providers.
Dr. Lee says she has been quite interested in patient-provider e-communication for a while, pointing out her interest in consumer technology, and how the “stakes get raised” when such modes of communication like e-mail or Facebook enter the healthcare realm. She says that for this particular project she was interested in how to improve the quality of e-communication between patients and their doctors. “So in order to improve you have to understand best practices and what the best recommended behaviors are. That led us to the guidelines; even before you try to change behavior, see what the desirable behaviors are. So we wanted to see what the guidelines were suggesting about physician behaviors when it came to e-communication,” she says.
Lee and her colleagues came to a conclusion that there are major weaknesses in current guidelines for electronic communication between patients and providers. In looking at the guidelines that Lee and her team reviewed—from six professional societies, including from the American College of Physicians (ACP) and the American Medical Informatics Association (AMIA)—the research team noticed two main areas of suggested practices: one on the technical side and the other on the relational communication side.
Lee says that her team saw that the guidelines were well-intentioned but slightly outdated. “One suggestion was that if you’re answering emails from your home, remember to print them off and put them in the patient record when you get back to the office. But that’s not what’s happening in real world, and that’s not how people are practicing with EHRs [electronic health records],” she says. Indeed, the AMIA guidelines, Lee notes, are about 20 years old, while the most recent set that was reviewed across any of the associations was from ACP, last updated in 2013.
What’s more, a lot of the considerations in the guidelines are things that are dealt with by IT systems, and are not issues that providers individually have to worry about or be concerned with, Lee says. For instance, vendors are choosing encryption systems, which is not something that individual doctors have to worry about. “A lot of these guidelines are irrelevant for everyday practitioners,” Lee attests. “When it comes to the relational side, a lot of guidelines are well-intentioned but it’s just not about how most people are using e-mail today.”
Another example she gives is doctors asking patients to use auto-reply functions to make sure they have received the doctor’s message, or even using the auto-reply for every single message. “This is out-of-step for how people are using e-communication,” says Lee. “So part of the weakness is being out-of-date and part is that providers need much more guidance about which phrases, messages, or emotional support are best used in which circumstances. In some circumstances, for instance, secure messages work well and for certain others, you should stay away from them,” she notes.
And then there are some cases in which it’s not just the physician, but others on the team such as physician assistants and nurses who are reading the patient messages, too. These are things the guidelines don’t really talk about,” she says, adding that a way to improve the guidelines would be to look at the content of the communication—and inappropriate versus appropriate circumstances—more than just the technology itself.
The Impact of Provider-Patient E-communication
Researchers from the Wisconsin School of Business at the University of Wisconsin–Madison recently stated in a paper that although there are plenty of frequently suggested benefits of “e-visits” and of electronic communication between providers and patients, such as enabling providers to give patients a low-cost alternative to visiting the doctor’s office, there could also be unintended consequences involved.
This study, which took place at a large U.S. health system and included electronic communication between patients and providers, mostly in the form of secure messaging via patient portals, revealed the following core conclusions: providers adopting e-visits experienced a 6-percent increase in office visits; the additional visits resulted in an additional 45 minutes per month of extra time doctors spent on those visits; to make up for that additional time spent on office visits, there was a 15-percent reduction in the number of new patients seen each month by those providers; and there was no observable improvement in patient health between those utilizing e-visits and those who did not.
When asked about this study, Lee said this type of research is only just starting to come out, meaning definitive conclusions are unclear. “It could save some visits when questions could be addressed electronically that you used to need visits for, but on the other hand, now that you have expanded access, it’s easier for people to get in contact, [meaning] more visits would be a result of that. I can see it go both ways and we’re still not sure at this point,” she says, adding that the next logical step is figuring out how to make a linkage between improved e-communication and improve health.
Lee also points out that the security behind e-communication is not a roadblock like it once was in the pre-meaningful use days. She notes that most health systems have already made an investment in secure messaging protocols due to different meaningful use regulations and are now committed to the technology. What’s left to figure out is how to make it work and optimizing its use. “I do think that there might be a bit of a security roadblock for patients in terms of convenience; secure messaging requires an extra login, so it’s different than e-mail in that sense. Patients have that extra level of protection since these messages are encrypted, which is good in terms of a protection sense, but some patients might see it as inconvenient. But that’s really the only roadblock I can think of,” she says.