Research Paper: Web Messaging: A New Tool for Patient-Physician Communication

Design: Eight providers and their staff and patients were surveyed on use of this web messaging system, and physician productivity was measured with Relative Value Unit (RVU) and office visit data. Results: 36.9% (238/645) of registered users responded to the survey. The web messaging system was preferred over phone calls by both providers and patients for the communication of non-urgent problems. A great majority of patients found it easy to use (88.8% or 206/232) and were satisfied (85.8% or 199/232). Satisfaction was significantly associated with timely provider response (Goodman-Kruskal Gamma = 0.667, 95% CI = 0.546–0.789). Clinicians were also favorable to the system and, despite concerns, were not inundated with messages. Most found it easy to use, perceived it to improve patient communication, and valued the insurance reimbursement capability. Furthermore, the system did not have a negative impact on physician productivity. Conclusion: A patient-provider web messaging system, which provides a combination of security and access controls, customized routing, rich knowledge content, and insurance reimbursement capability, is a useful addition to the array of communication options available to health care providers and their patients. ■ J Am Med Inform Assoc. 2003;10:260–270. DOI 10.1197/jamia.M1259. would influence their choice of health plans and 56% responding that this capability would influence their choice of physicians. In reality, however, very few patients actually communicate with their physicians electronically. Lacher et al. 14 revealed that while 82% of physicians stated they use computers for personal or professional reasons, fewer than 7% acknowledged exchanging e-mail with their patients. In a study by Moyer et al.,13 two-thirds of all patients revealed they would like to communicate with their doctors via e-mail, yet only 10% of e-mail users reported ever having done so. Similarly, Sittig et al.6 found that only 6% of patients had ever sent an e-mail message to their provider. One study reported 79% of physicians had no desire to communicate directly with patients via e-mail.9 Several barriers discourage the use of e-mail between patients and providers. One is physicians’ fear of being inundated with messages. They believe that e-mail would add to already busy schedules with no possibility of financial reimbursement.9,13 Some patients, on the other hand, have expressed apprehension about using this technology with their provider because of potential slow responses, especially those that need immediate attention.6,13,15,16 Privacy and security concerns also increase many physicians’ and patients’ reluctance to communicate via e-mail.6,7,9,13,16,17 Unencrypted messages may be intercepted and read by unauthorized people. E-mail may be left open on the screen of a computer, allowing unauthorized individuals to see them. Computer terminals may be shared at work or at home, minimizing privacy. Methods other than conventional e-mail are being studied and developed to address the concerns cited above, as consumer demand is so high. CHESS (Comprehensive Health Enhancement Support System) is a home-based interactive computer system developed at the University of Wisconsin–Madison to provide information, decision-making, and emotional support to people facing life-threatening illnesses.18 A number of studies have reported its usefulness to patients by improving their quality of life and their utilization of health care.19–21 More recently, a triage-based e-mail system was investigated in a case-controlled study at the University of Michigan and submitted to the Journal of General Internal Medicine for publication. In this study, Katz et al. found that e-mail increased the communication burden on physicians and staff and had little effect on physicians’ or patients’ attitudes toward communication. The study concluded e-mail was of limited use in improving the efficiency and effectiveness of clinical care.22 Secure web messaging offers another option to electronic communication by providing protected, encrypted communication. Messages can be automatically structured and triaged to appropriate staff, minimizing workload.13 Websites can also provide education and other useful information. Because of their centralized nature, they have the potential to be more consistent and reliable.23 However, to the authors’ knowledge, presently no studies are available about the performance of secure patient-provider Web messaging. The RelayHealth system, developed by the RelayHealth Corporation (formerly Healinx Corporation) of Emeryville, California, provides web-based provider-patient communication services that are secure and clinically structured. Besides electronic messaging, the system offers non-urgent asynchronous consultations, appointments, medication refills, and preventive care reminders via an Internet browser. Security is achieved with 128bit Secure-Socket-Layer (SSL) 3.0 encrypted messages and a secure server with a firewall blocking access to unauthorized individuals. The messages can be read only by the registered doctor, his/her authorized staff, and patients with their personal login name and password. The system allows providers to control which patients may have access to the services and to charge patients for message responses.24 This study evaluates this patient-physician web messaging system to determine how it satisfies patients’ demand to communicate electronically with and have improved access to their providers; it also evaluates provider satisfaction and examines the impact on practice productivity. We hypothesized that productivity would not be impaired and might be enhanced through better use of “micro down-time,” ability to batchprocess messages rather than handling them one by one, decreased time and increased convenience of handling electronic messages over phone calls, and replacement of lower-level office visits with higher-level office visits to generate more revenue.