E-mail Communications in Family Practice What Do Patients Expect?

E-mail use has been reported in a variety of broad areas, including biomedical communication, general patient surveys^2,3 and medical practice^4-8; it is also used by several institutions.⁹ Approximately half of all US adults report that they currently use E-mail at home or at work, and as many as 40% of patients would use E-mail to communicate with their physicians.¹⁰ Experts estimate that 5% to 10% of physicians are already communicating with their patients by E-mail.¹¹

There are many potential benefits to E-mail in medical practice.^10,12 It allows for efficient asynchronous communication. It eliminates phone tag, and the caller does not incur long-distance phone charges. E-mail is also a good marketing tool and lends itself well to linkage with patient education Web sites. Another advantage is improved documentation. By simply printing and including or copying all E-mail communications in the medical record, excellent documentation of the provider-patient discourse is obtained. This form of provider-patient communication may be very beneficial financially in capitated environments, where simple medical problems can be addressed without an office visit.

Along with these benefits, however, come significant potential disadvantages.^3,12,13 Many physicians are afraid that E-mail would allow patients too much access, and consequently they are reluctant to embrace this innovative communication tool. There are related concerns that patients will barrage their physicians with excessive E-mails on trivial matters. It could become another physician hassle factor of practice and create one more thing to do at the end of the day. Also, there are genuine fears that patients will think of E-mail as a hot line to the physician’s office and inappropriately use it for emergent situations, creating additional liabilities for the physician and staff. There are also very real concerns about privacy and security: How can this exchange of information between providers and patients be protected and kept confidential if it is on the Internet?

Although it is generally agreed that some guidelines are required to manage and regulate E-mail communication between patients and their health care providers,^14,15 it is equally important to assess the actual desire for this technology in specific practices. We conducted a needs assessment for E-mail communication between family physicians, other health care providers, and their patients attending 6 family practice clinics in central Texas.

Methods

Study Design and Setting

We performed a cross-sectional, in-person prevalence survey using patients with scheduled appointments to see a primary care physician in 6 of the 18 clinics of the Scott & White Healthcare System in central Texas: Northside Clinic and Santa Fe Clinic in Temple, Belton Clinic, Killeen Clinic, Bryan/College Station Clinic, and Waco Clinic. Temple, Belton, and Killeen are all located in Bell County, while Bryan/College Station is located in Brazos County, the site of the main campus of Texas A&M University. The Scott & White Institutional Review Board reviewed the study protocol.

Study Participants and Data Collection

A concerted effort was made to enroll all patients who presented to each of the 6 clinics on preselected days for the surveys. The days differed by clinic and were selected to enroll a specified number of patients according to clinic size for a total of approximately 1000 subjects. The newly opened Northside Clinic was an exception.

The survey included questions about: (1) current Internet and E-mail access; (2) how likely it was that patients would use E-mail for selected clinical services, if available, scored on a 5-point Likert scale; (3) what in their opinion was a reasonable response time to their E-mail communication about routine laboratory results, prescription refills, and medical questions; and (4) demographic information including sex, age, race/ethnicity, education, and annual family income.

Statistical Analysis

Data management and analysis were performed using SPSS software¹⁶ on a personal computer. We determined the proportion of patients with access to the Internet and E-mail by clinic. Overall, reported desired areas for using E-mail for selected clinical services were computed as the combined responses of 3 to 5 on the 5-point Likert scale. Reported desired areas for using E-mail were also computed as mean responses on the scale. We determined patient expectations regarding the timeliness of their E-mail queries. Group differences were assessed for significance using the c² statistic or Fisher exact test for categorical data and the nonparametric Kruskal-Wallis analysis of variance test for ordinal (Likert-style) data. Finally, multivariate logistic regression modeling was used to control for measured covariates on the 5 main outcome variables. All tests were 2-tailed and considered significant at P less than .05.

Results

E-mail Access

Overall, 54.3% of the patients reported having E-mail access, with a significant wide variation (33%-75%) among the 6 clinics Table 1. Internet access rates mirrored those of E-mail access rates.

Desired Areas for Using E-mail

On the basis of the combined responses of 3 to 5 on the 5-point Likert scale, we found that patients most wanted to use E-mail to request prescription refills (90%), for nonurgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Using E-mail to make or cancel appointments (78%) was the area of least interest reported by all patients Figure 1.

The reported desire to use E-mail for selected clinical services varied by patient demographic characteristics, using mean responses on the 5-point Likert scale. However, after multivariate adjustment for other measured variables, we only found 2 significant associations. African Americans were somewhat less likely than other groups to want to use E-mail to get laboratory results or test reports, and older patients were significantly less interested in using E-mail to consult a nurse on nonurgent simple medical questions.

Timeliness of Responses to E-mail Queries

Patients’ expectations of the timeliness of responses to their E-mail queries varied significantly by selected clinical services but not by clinic. For routine laboratory results, for example, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26% Table 2.

No sex or racial/ethnic differences were found regarding the timeliness of responses to E-mail queries for the 3 selected clinical services. Additionally, there were no demographic differences for the timeliness of responses to E-mail queries about prescription refills. However, there were significant age group and income differences in the timeliness of responses to patients’ E-mail queries on laboratory results or test reports. Although the majority of patients in each age group expected a response to their E-mail queries on laboratory results or test reports within 24 hours, only 6% of patients aged 65 years and older expected a response later than 24 hours compared with 20% to 29% of patients in other age groups. Surprisingly, patients with annual family incomes at both extremes had significantly higher expectations for the timeliness of responses to E-mail queries on laboratory results or test reports than their counterparts in the middle income brackets. Also, patients with educational levels at both extremes, particularly those with less than a high school education, had significantly higher expectations regarding the timeliness of responses to queries on medical questions Table 3.

Discussion

Our findings confirmed some of our suppositions and brought new information to light. We were not surprised to find that slightly more than 50% of our patients had E-mail and Internet access. This statistic is similar to those reported in other published literature.^2,3 However, we could not completely explain the large variation from site to site within our own health care system. One plausible explanation for the relatively high rate of E-mail access observed at the Bryan/College Station Clinic is its location in a university town, where the clinic clientele is more likely to have an overall higher level of education than that in some of our other sites.

Recently it was reported in the Dallas Business Journal¹⁷ that nearly half of 1000 adult patients interviewed during a Laurus Health.com telephone survey said they would like to have E-mail access to their physician’s appointment scheduling system. In our study, we found a very strong desire for this service (78%) among our patient population. The Laurus Health.com survey also reported that 37% of all patients wanted electronic access to their test results. Our study found that 84% of our patients with E-mail access desired this capability. In fact, our study found a degree of interest in electronic communication with their health care provider that was very similar to that of a University of Michigan study of patients in a general medicine clinic. In the University of Michigan study, 70% of patients surveyed indicated their willingness to communicate with their health care provider using E-mail.¹⁸

Although it has been reported that consumers are 35% more likely to choose a physician who offers to communicate with patients using E-mail,¹⁷ this is not a marketing strategy that physicians should take lightly. From our study, one could assume that patients have very high expectations regarding response times for this form of provider-patient communication. One of the more disconcerting findings of our study was the exceptionally rapid turnaround time patients expected for obtaining laboratory results or test reports, prescription refills, and answers to their medical questions. Knowing that patients would expect these results within 24 hours at least 70% of the time may be unsettling to many physicians who would feel that this time frame is not attainable with the current system of laboratory processing and handling patient requests. Meeting those expectations may require major changes for physician practices.

The Health Institution Portability and Accountability Act of 1996 places comprehensive new security requirements on the US health care industry.^19,20 The standards for privacy and protection of all health information that can be linked directly to an individual mandate that all patient E-mail communication be as secure as possible. Physicians using E-mail with their patients must be familiar and be compliant with these federal regulations.* The Journal of the American Medical Informatics Association also recently published “guidelines for the clinical use of electronic mail with patients.”¹⁴ This is an excellent reference for any physician considering E-mail communication and is available at their Web site (www.amia.org).

Limitations

Our study has several limitations. The surveys involved patients who were being seen in 6 clinics in central Texas; therefore, this sample may not truly represent the population at large. Also, all patients were scheduled to see family physicians, limiting the ability to generalize our findings to other disciplines. Future studies should expand beyond one discipline to include other primary care and specialty care departments. Also, the survey results reflect patients’ self-reported anticipated behavior if services were available and do not reflect actual usage. Another limitation is the small number of racial/ethnic minority groups.

The survey instrument we used lacked specificity on some questions. For example, we do not know whether patient expectations vary by test (ie, Do patients expect a faster response to a blood test than to an x-ray or a Papanicolaou test?) Future studies should use more specific survey instruments. Our study did not include an assessment of urban versus rural differences in E-mail communication, although it would seem that factors such as access, time, and lack of knowledge about this new technology may make a difference.²¹ Additionally, many previous studies have unveiled disparities in health care access between urban and rural populations, defined as places with fewer than 2500 residents. For example, the 25% of Americans who live in rural areas are less likely to use preventive screening services and wear seat belts. Also, in 1996, 20% of the rural population was uninsured, compared with 16% of the urban population.²² Future studies should incorporate this variable in the data collection process.

Conclusions

In central Texas the majority of patients attending⁶ family practice clinics reported having access to E-mail and indicated they would use it to request prescription refills, obtain routine laboratory results or test reports, and for nonurgent consultations independent of their age group, sex, education, or income. Also, there was a wide variability of E-mail access from practice to practice. Independent of sex or race, patients have high expectations that these tasks can be completed in a relatively short time.

Acknowledgments

We wish to acknowledge the contributions made by all the family physicians, operations managers, and supervisors at the 6 participating clinics during the data collection. We are also grateful to Pat Kirkpatrick for her initial ideas, Saundra Mason for data management, and Marcine Chambers, Linda Teer, and Virginia Gray for secretarial support.

Related resources

• American Medical Informatics Association—nonprofit organization of individuals, institutions and corporations dedicated to developing and using information technologies to improve health care. http://www.amia.org
• California Academy Of Family Physicians—offers monograph on “Making the Most of Physician-Patient E-mail.” http://www.familydocs.org

E-mail use has been reported in a variety of broad areas, including biomedical communication, general patient surveys^2,3 and medical practice^4-8; it is also used by several institutions.⁹ Approximately half of all US adults report that they currently use E-mail at home or at work, and as many as 40% of patients would use E-mail to communicate with their physicians.¹⁰ Experts estimate that 5% to 10% of physicians are already communicating with their patients by E-mail.¹¹

There are many potential benefits to E-mail in medical practice.^10,12 It allows for efficient asynchronous communication. It eliminates phone tag, and the caller does not incur long-distance phone charges. E-mail is also a good marketing tool and lends itself well to linkage with patient education Web sites. Another advantage is improved documentation. By simply printing and including or copying all E-mail communications in the medical record, excellent documentation of the provider-patient discourse is obtained. This form of provider-patient communication may be very beneficial financially in capitated environments, where simple medical problems can be addressed without an office visit.

Along with these benefits, however, come significant potential disadvantages.^3,12,13 Many physicians are afraid that E-mail would allow patients too much access, and consequently they are reluctant to embrace this innovative communication tool. There are related concerns that patients will barrage their physicians with excessive E-mails on trivial matters. It could become another physician hassle factor of practice and create one more thing to do at the end of the day. Also, there are genuine fears that patients will think of E-mail as a hot line to the physician’s office and inappropriately use it for emergent situations, creating additional liabilities for the physician and staff. There are also very real concerns about privacy and security: How can this exchange of information between providers and patients be protected and kept confidential if it is on the Internet?

Although it is generally agreed that some guidelines are required to manage and regulate E-mail communication between patients and their health care providers,^14,15 it is equally important to assess the actual desire for this technology in specific practices. We conducted a needs assessment for E-mail communication between family physicians, other health care providers, and their patients attending 6 family practice clinics in central Texas.

Methods

Study Design and Setting

We performed a cross-sectional, in-person prevalence survey using patients with scheduled appointments to see a primary care physician in 6 of the 18 clinics of the Scott & White Healthcare System in central Texas: Northside Clinic and Santa Fe Clinic in Temple, Belton Clinic, Killeen Clinic, Bryan/College Station Clinic, and Waco Clinic. Temple, Belton, and Killeen are all located in Bell County, while Bryan/College Station is located in Brazos County, the site of the main campus of Texas A&M University. The Scott & White Institutional Review Board reviewed the study protocol.

Study Participants and Data Collection

A concerted effort was made to enroll all patients who presented to each of the 6 clinics on preselected days for the surveys. The days differed by clinic and were selected to enroll a specified number of patients according to clinic size for a total of approximately 1000 subjects. The newly opened Northside Clinic was an exception.

The survey included questions about: (1) current Internet and E-mail access; (2) how likely it was that patients would use E-mail for selected clinical services, if available, scored on a 5-point Likert scale; (3) what in their opinion was a reasonable response time to their E-mail communication about routine laboratory results, prescription refills, and medical questions; and (4) demographic information including sex, age, race/ethnicity, education, and annual family income.

Statistical Analysis

Data management and analysis were performed using SPSS software¹⁶ on a personal computer. We determined the proportion of patients with access to the Internet and E-mail by clinic. Overall, reported desired areas for using E-mail for selected clinical services were computed as the combined responses of 3 to 5 on the 5-point Likert scale. Reported desired areas for using E-mail were also computed as mean responses on the scale. We determined patient expectations regarding the timeliness of their E-mail queries. Group differences were assessed for significance using the c² statistic or Fisher exact test for categorical data and the nonparametric Kruskal-Wallis analysis of variance test for ordinal (Likert-style) data. Finally, multivariate logistic regression modeling was used to control for measured covariates on the 5 main outcome variables. All tests were 2-tailed and considered significant at P less than .05.

Results

E-mail Access

Overall, 54.3% of the patients reported having E-mail access, with a significant wide variation (33%-75%) among the 6 clinics Table 1. Internet access rates mirrored those of E-mail access rates.

Desired Areas for Using E-mail

On the basis of the combined responses of 3 to 5 on the 5-point Likert scale, we found that patients most wanted to use E-mail to request prescription refills (90%), for nonurgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Using E-mail to make or cancel appointments (78%) was the area of least interest reported by all patients Figure 1.

The reported desire to use E-mail for selected clinical services varied by patient demographic characteristics, using mean responses on the 5-point Likert scale. However, after multivariate adjustment for other measured variables, we only found 2 significant associations. African Americans were somewhat less likely than other groups to want to use E-mail to get laboratory results or test reports, and older patients were significantly less interested in using E-mail to consult a nurse on nonurgent simple medical questions.

Timeliness of Responses to E-mail Queries

Patients’ expectations of the timeliness of responses to their E-mail queries varied significantly by selected clinical services but not by clinic. For routine laboratory results, for example, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26% Table 2.

No sex or racial/ethnic differences were found regarding the timeliness of responses to E-mail queries for the 3 selected clinical services. Additionally, there were no demographic differences for the timeliness of responses to E-mail queries about prescription refills. However, there were significant age group and income differences in the timeliness of responses to patients’ E-mail queries on laboratory results or test reports. Although the majority of patients in each age group expected a response to their E-mail queries on laboratory results or test reports within 24 hours, only 6% of patients aged 65 years and older expected a response later than 24 hours compared with 20% to 29% of patients in other age groups. Surprisingly, patients with annual family incomes at both extremes had significantly higher expectations for the timeliness of responses to E-mail queries on laboratory results or test reports than their counterparts in the middle income brackets. Also, patients with educational levels at both extremes, particularly those with less than a high school education, had significantly higher expectations regarding the timeliness of responses to queries on medical questions Table 3.

Discussion

Our findings confirmed some of our suppositions and brought new information to light. We were not surprised to find that slightly more than 50% of our patients had E-mail and Internet access. This statistic is similar to those reported in other published literature.^2,3 However, we could not completely explain the large variation from site to site within our own health care system. One plausible explanation for the relatively high rate of E-mail access observed at the Bryan/College Station Clinic is its location in a university town, where the clinic clientele is more likely to have an overall higher level of education than that in some of our other sites.

Recently it was reported in the Dallas Business Journal¹⁷ that nearly half of 1000 adult patients interviewed during a Laurus Health.com telephone survey said they would like to have E-mail access to their physician’s appointment scheduling system. In our study, we found a very strong desire for this service (78%) among our patient population. The Laurus Health.com survey also reported that 37% of all patients wanted electronic access to their test results. Our study found that 84% of our patients with E-mail access desired this capability. In fact, our study found a degree of interest in electronic communication with their health care provider that was very similar to that of a University of Michigan study of patients in a general medicine clinic. In the University of Michigan study, 70% of patients surveyed indicated their willingness to communicate with their health care provider using E-mail.¹⁸

Although it has been reported that consumers are 35% more likely to choose a physician who offers to communicate with patients using E-mail,¹⁷ this is not a marketing strategy that physicians should take lightly. From our study, one could assume that patients have very high expectations regarding response times for this form of provider-patient communication. One of the more disconcerting findings of our study was the exceptionally rapid turnaround time patients expected for obtaining laboratory results or test reports, prescription refills, and answers to their medical questions. Knowing that patients would expect these results within 24 hours at least 70% of the time may be unsettling to many physicians who would feel that this time frame is not attainable with the current system of laboratory processing and handling patient requests. Meeting those expectations may require major changes for physician practices.

The Health Institution Portability and Accountability Act of 1996 places comprehensive new security requirements on the US health care industry.^19,20 The standards for privacy and protection of all health information that can be linked directly to an individual mandate that all patient E-mail communication be as secure as possible. Physicians using E-mail with their patients must be familiar and be compliant with these federal regulations.* The Journal of the American Medical Informatics Association also recently published “guidelines for the clinical use of electronic mail with patients.”¹⁴ This is an excellent reference for any physician considering E-mail communication and is available at their Web site (www.amia.org).

Limitations

Our study has several limitations. The surveys involved patients who were being seen in 6 clinics in central Texas; therefore, this sample may not truly represent the population at large. Also, all patients were scheduled to see family physicians, limiting the ability to generalize our findings to other disciplines. Future studies should expand beyond one discipline to include other primary care and specialty care departments. Also, the survey results reflect patients’ self-reported anticipated behavior if services were available and do not reflect actual usage. Another limitation is the small number of racial/ethnic minority groups.

The survey instrument we used lacked specificity on some questions. For example, we do not know whether patient expectations vary by test (ie, Do patients expect a faster response to a blood test than to an x-ray or a Papanicolaou test?) Future studies should use more specific survey instruments. Our study did not include an assessment of urban versus rural differences in E-mail communication, although it would seem that factors such as access, time, and lack of knowledge about this new technology may make a difference.²¹ Additionally, many previous studies have unveiled disparities in health care access between urban and rural populations, defined as places with fewer than 2500 residents. For example, the 25% of Americans who live in rural areas are less likely to use preventive screening services and wear seat belts. Also, in 1996, 20% of the rural population was uninsured, compared with 16% of the urban population.²² Future studies should incorporate this variable in the data collection process.

Conclusions

In central Texas the majority of patients attending⁶ family practice clinics reported having access to E-mail and indicated they would use it to request prescription refills, obtain routine laboratory results or test reports, and for nonurgent consultations independent of their age group, sex, education, or income. Also, there was a wide variability of E-mail access from practice to practice. Independent of sex or race, patients have high expectations that these tasks can be completed in a relatively short time.

Acknowledgments

We wish to acknowledge the contributions made by all the family physicians, operations managers, and supervisors at the 6 participating clinics during the data collection. We are also grateful to Pat Kirkpatrick for her initial ideas, Saundra Mason for data management, and Marcine Chambers, Linda Teer, and Virginia Gray for secretarial support.

Related resources

• American Medical Informatics Association—nonprofit organization of individuals, institutions and corporations dedicated to developing and using information technologies to improve health care. http://www.amia.org
• California Academy Of Family Physicians—offers monograph on “Making the Most of Physician-Patient E-mail.” http://www.familydocs.org

E-mail use has been reported in a variety of broad areas, including biomedical communication, general patient surveys^2,3 and medical practice^4-8; it is also used by several institutions.⁹ Approximately half of all US adults report that they currently use E-mail at home or at work, and as many as 40% of patients would use E-mail to communicate with their physicians.¹⁰ Experts estimate that 5% to 10% of physicians are already communicating with their patients by E-mail.¹¹

There are many potential benefits to E-mail in medical practice.^10,12 It allows for efficient asynchronous communication. It eliminates phone tag, and the caller does not incur long-distance phone charges. E-mail is also a good marketing tool and lends itself well to linkage with patient education Web sites. Another advantage is improved documentation. By simply printing and including or copying all E-mail communications in the medical record, excellent documentation of the provider-patient discourse is obtained. This form of provider-patient communication may be very beneficial financially in capitated environments, where simple medical problems can be addressed without an office visit.

Along with these benefits, however, come significant potential disadvantages.^3,12,13 Many physicians are afraid that E-mail would allow patients too much access, and consequently they are reluctant to embrace this innovative communication tool. There are related concerns that patients will barrage their physicians with excessive E-mails on trivial matters. It could become another physician hassle factor of practice and create one more thing to do at the end of the day. Also, there are genuine fears that patients will think of E-mail as a hot line to the physician’s office and inappropriately use it for emergent situations, creating additional liabilities for the physician and staff. There are also very real concerns about privacy and security: How can this exchange of information between providers and patients be protected and kept confidential if it is on the Internet?

Although it is generally agreed that some guidelines are required to manage and regulate E-mail communication between patients and their health care providers,^14,15 it is equally important to assess the actual desire for this technology in specific practices. We conducted a needs assessment for E-mail communication between family physicians, other health care providers, and their patients attending 6 family practice clinics in central Texas.

Methods

Study Design and Setting

We performed a cross-sectional, in-person prevalence survey using patients with scheduled appointments to see a primary care physician in 6 of the 18 clinics of the Scott & White Healthcare System in central Texas: Northside Clinic and Santa Fe Clinic in Temple, Belton Clinic, Killeen Clinic, Bryan/College Station Clinic, and Waco Clinic. Temple, Belton, and Killeen are all located in Bell County, while Bryan/College Station is located in Brazos County, the site of the main campus of Texas A&M University. The Scott & White Institutional Review Board reviewed the study protocol.

Study Participants and Data Collection

A concerted effort was made to enroll all patients who presented to each of the 6 clinics on preselected days for the surveys. The days differed by clinic and were selected to enroll a specified number of patients according to clinic size for a total of approximately 1000 subjects. The newly opened Northside Clinic was an exception.

The survey included questions about: (1) current Internet and E-mail access; (2) how likely it was that patients would use E-mail for selected clinical services, if available, scored on a 5-point Likert scale; (3) what in their opinion was a reasonable response time to their E-mail communication about routine laboratory results, prescription refills, and medical questions; and (4) demographic information including sex, age, race/ethnicity, education, and annual family income.

Statistical Analysis

Data management and analysis were performed using SPSS software¹⁶ on a personal computer. We determined the proportion of patients with access to the Internet and E-mail by clinic. Overall, reported desired areas for using E-mail for selected clinical services were computed as the combined responses of 3 to 5 on the 5-point Likert scale. Reported desired areas for using E-mail were also computed as mean responses on the scale. We determined patient expectations regarding the timeliness of their E-mail queries. Group differences were assessed for significance using the c² statistic or Fisher exact test for categorical data and the nonparametric Kruskal-Wallis analysis of variance test for ordinal (Likert-style) data. Finally, multivariate logistic regression modeling was used to control for measured covariates on the 5 main outcome variables. All tests were 2-tailed and considered significant at P less than .05.

Results

E-mail Access

Overall, 54.3% of the patients reported having E-mail access, with a significant wide variation (33%-75%) among the 6 clinics Table 1. Internet access rates mirrored those of E-mail access rates.

Desired Areas for Using E-mail

On the basis of the combined responses of 3 to 5 on the 5-point Likert scale, we found that patients most wanted to use E-mail to request prescription refills (90%), for nonurgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Using E-mail to make or cancel appointments (78%) was the area of least interest reported by all patients Figure 1.

The reported desire to use E-mail for selected clinical services varied by patient demographic characteristics, using mean responses on the 5-point Likert scale. However, after multivariate adjustment for other measured variables, we only found 2 significant associations. African Americans were somewhat less likely than other groups to want to use E-mail to get laboratory results or test reports, and older patients were significantly less interested in using E-mail to consult a nurse on nonurgent simple medical questions.

Timeliness of Responses to E-mail Queries

Patients’ expectations of the timeliness of responses to their E-mail queries varied significantly by selected clinical services but not by clinic. For routine laboratory results, for example, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26% Table 2.

No sex or racial/ethnic differences were found regarding the timeliness of responses to E-mail queries for the 3 selected clinical services. Additionally, there were no demographic differences for the timeliness of responses to E-mail queries about prescription refills. However, there were significant age group and income differences in the timeliness of responses to patients’ E-mail queries on laboratory results or test reports. Although the majority of patients in each age group expected a response to their E-mail queries on laboratory results or test reports within 24 hours, only 6% of patients aged 65 years and older expected a response later than 24 hours compared with 20% to 29% of patients in other age groups. Surprisingly, patients with annual family incomes at both extremes had significantly higher expectations for the timeliness of responses to E-mail queries on laboratory results or test reports than their counterparts in the middle income brackets. Also, patients with educational levels at both extremes, particularly those with less than a high school education, had significantly higher expectations regarding the timeliness of responses to queries on medical questions Table 3.

Discussion

Our findings confirmed some of our suppositions and brought new information to light. We were not surprised to find that slightly more than 50% of our patients had E-mail and Internet access. This statistic is similar to those reported in other published literature.^2,3 However, we could not completely explain the large variation from site to site within our own health care system. One plausible explanation for the relatively high rate of E-mail access observed at the Bryan/College Station Clinic is its location in a university town, where the clinic clientele is more likely to have an overall higher level of education than that in some of our other sites.

Recently it was reported in the Dallas Business Journal¹⁷ that nearly half of 1000 adult patients interviewed during a Laurus Health.com telephone survey said they would like to have E-mail access to their physician’s appointment scheduling system. In our study, we found a very strong desire for this service (78%) among our patient population. The Laurus Health.com survey also reported that 37% of all patients wanted electronic access to their test results. Our study found that 84% of our patients with E-mail access desired this capability. In fact, our study found a degree of interest in electronic communication with their health care provider that was very similar to that of a University of Michigan study of patients in a general medicine clinic. In the University of Michigan study, 70% of patients surveyed indicated their willingness to communicate with their health care provider using E-mail.¹⁸

Although it has been reported that consumers are 35% more likely to choose a physician who offers to communicate with patients using E-mail,¹⁷ this is not a marketing strategy that physicians should take lightly. From our study, one could assume that patients have very high expectations regarding response times for this form of provider-patient communication. One of the more disconcerting findings of our study was the exceptionally rapid turnaround time patients expected for obtaining laboratory results or test reports, prescription refills, and answers to their medical questions. Knowing that patients would expect these results within 24 hours at least 70% of the time may be unsettling to many physicians who would feel that this time frame is not attainable with the current system of laboratory processing and handling patient requests. Meeting those expectations may require major changes for physician practices.

The Health Institution Portability and Accountability Act of 1996 places comprehensive new security requirements on the US health care industry.^19,20 The standards for privacy and protection of all health information that can be linked directly to an individual mandate that all patient E-mail communication be as secure as possible. Physicians using E-mail with their patients must be familiar and be compliant with these federal regulations.* The Journal of the American Medical Informatics Association also recently published “guidelines for the clinical use of electronic mail with patients.”¹⁴ This is an excellent reference for any physician considering E-mail communication and is available at their Web site (www.amia.org).

Limitations

Our study has several limitations. The surveys involved patients who were being seen in 6 clinics in central Texas; therefore, this sample may not truly represent the population at large. Also, all patients were scheduled to see family physicians, limiting the ability to generalize our findings to other disciplines. Future studies should expand beyond one discipline to include other primary care and specialty care departments. Also, the survey results reflect patients’ self-reported anticipated behavior if services were available and do not reflect actual usage. Another limitation is the small number of racial/ethnic minority groups.

The survey instrument we used lacked specificity on some questions. For example, we do not know whether patient expectations vary by test (ie, Do patients expect a faster response to a blood test than to an x-ray or a Papanicolaou test?) Future studies should use more specific survey instruments. Our study did not include an assessment of urban versus rural differences in E-mail communication, although it would seem that factors such as access, time, and lack of knowledge about this new technology may make a difference.²¹ Additionally, many previous studies have unveiled disparities in health care access between urban and rural populations, defined as places with fewer than 2500 residents. For example, the 25% of Americans who live in rural areas are less likely to use preventive screening services and wear seat belts. Also, in 1996, 20% of the rural population was uninsured, compared with 16% of the urban population.²² Future studies should incorporate this variable in the data collection process.

Conclusions

In central Texas the majority of patients attending⁶ family practice clinics reported having access to E-mail and indicated they would use it to request prescription refills, obtain routine laboratory results or test reports, and for nonurgent consultations independent of their age group, sex, education, or income. Also, there was a wide variability of E-mail access from practice to practice. Independent of sex or race, patients have high expectations that these tasks can be completed in a relatively short time.

Acknowledgments

We wish to acknowledge the contributions made by all the family physicians, operations managers, and supervisors at the 6 participating clinics during the data collection. We are also grateful to Pat Kirkpatrick for her initial ideas, Saundra Mason for data management, and Marcine Chambers, Linda Teer, and Virginia Gray for secretarial support.

Related resources

• American Medical Informatics Association—nonprofit organization of individuals, institutions and corporations dedicated to developing and using information technologies to improve health care. http://www.amia.org
• California Academy Of Family Physicians—offers monograph on “Making the Most of Physician-Patient E-mail.” http://www.familydocs.org