Physicians' use of and attitudes toward electronic mail for patient communication

Determining the readiness of patients with renal failure to use health information technology

INTRODUCTION

Using information technology (IT) for purposes such as patient education and disease prevention and management is effective when patients are ready to use it. The objective of this study was to determine the readiness of patients with renal failure to use health IT.

METHODS

This study was performed on all dialysis patients in South Khorasan province (n = 263) using a 28-item questionnaire. The questionnaire consisted of (1) demographic information of participants and (2) questions concerning eight main factors including the need for information, desire to receive information, ability to use computers and the Internet, computers and the Internet anxiety, communication with physicians, using mobile phones and concerns about security and confidentiality of information. Descriptive statistics and Mann-Whitney and Kruskal-Wallis statistical tests were used to analyze the data.

RESULTS

About 15% of the participants stated that they do not want to receive information from the Internet. Anxiety and concern about Internet security and confidentiality were higher in women, married people, people over 60, villagers, and illiterate people (p < 0.05). Married people and people over 60 years had a higher desire to get information (p < 0.05). The rate of computer anxiety and Internet privacy concern was higher than average (p < 0.001). Most patients (34.2%) could only send text messages using mobile phones.

CONCLUSION

Despite the need of most patients to online health information, they do not use this information due to a lack of skills and experience to use IT. Therefore, the ability of users should be considered when developing IT-based interventions. Due to patients' concerns about Internet privacy, it is required to teach patients how to protect their privacy while using the Internet.

Electronic communication between family physicians and patients: Findings from a multisite survey of academic family physicians in Ontario

OBJECTIVE

To assess the proportion of academic family physicians using e-mail with patients and to explore related attitudes, barriers, and facilitators.

DESIGN

A 47-item questionnaire was created after a literature review, discussions with study team members, pretesting, and pilot testing. The questionnaire was disseminated electronically from June to August 2017.

SETTING

Ontario.

PARTICIPANTS

All family physicians affiliated with the Department of Family and Community Medicine at the University of Toronto.

MAIN OUTCOME MEASURES

Physician practices using e-mail (including barriers to and facilitators of e-mail use with patients), use of e-mail with other health care providers, use of communication technologies other than e-mail, and demographic and practice information.

RESULTS

A total of 1553 surveys were disseminated and 865 responses received (56% response rate). Overall, 610 respondents met inclusion criteria. Of these respondents, 43% (265 of 610) personally sent e-mails to patients in a typical week. An additional 21% (126 of 610) reported that they did not personally e-mail patients, but their clinic staff did. Patient convenience and a decrease in the need for telephone communication were the most commonly noted reasons for e-mail use. Facilitators of e-mail use included integration with the electronic medical record, enhanced e-mail access control, security features, and financial compensation. Barriers to e-mail use included privacy and security concerns, concerns about inappropriate e-mail use by patients, and the creation of unrealistic expectations about physician availability.

CONCLUSION

E-mail use between academic family physicians and patients was found to be much higher than shown in previous studies of Canadian physicians. This finding might have been owing to unique aspects of academic medicine, remuneration via capitation, or other factors. Efforts to increase physician use of e-mail with patients should address concerns related to privacy and security, electronic medical record integration, and financial compensation.

Internet access, usage and trust among medical professionals in China: A web-based survey

OBJECTIVES

Social media has changed methods of communication in the medical profession. As part of a "doctor as communicator" strategy, Chinese medical professionals are actively embracing social media, which may have an impact on tense physician-patient relationships in China. This paper aims to examine a pattern of Internet access, Internet usage, and trust among Chinese medical professionals and further explores the reasons for these relationships on an individual level.

DESIGNS

A web-based questionnaire was designed, based on a media literacy model, and was divided into 3 dimensions: public information, general medical information, and specialty information. After a two-round pilot study, 1001 physicians were included. Additionally, 4 interviewees were chosen to participate in in-depth interviews and content analysis was performed. Data were analyzed using SPSS 25.0.

RESULTS

Findings showed that new media has become a major approach for medical professionals in China to retrieve and get access to various information. However, they still trust traditional media (n = 1001, P < 0.01) and professional journals more (n = 1001, P < 0.01). Internet access, usage, and trust were positively correlated (r = 0.185-0.344, P < 0.01). Regarding usage habits, 47.66% of the participating physicians would practice science popularization through their new media accounts and 71.23% would forward approved health information within their professional realm. A validated instrument can be provided for further related studies.

CONCLUSIONS

Science popularization is a specific usage of new media among Chinese medical professionals, through which they have achieved new authority and empowered communication because of self-media. To some extent, physician-patient relationships in China can be improved because this online interaction is conducive to building harmonious and lasting offline physician-patient relationships.

American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations

Communication is critical to strong patient-physician relationships and high-quality health care. In recent years, advances in health information technology have altered how patients and doctors interact and communicate. Increasingly, e-communication outside of in-person clinical encounters occurs in many ways, including through e-mail, patient-portals, texting, and messaging applications. This American College of Physicians (ACP) position paper provides ethics and professionalism guidance for these forms of e-communication to help maintain trust in patient-physician relationships and the profession and alignment between patient and physician expectations.

Communication Technology Use and Preferences for Pregnant Women and Their Caregivers

The rapid evolution of communication technologies has created new ways for healthcare consumers to manage their health. In a mixed-methods study, we examined technology use and willingness to use in pregnant women and caregivers, using surveys and semi-structured interviews. Most participants had used text messaging, automated phone calls, Skype/FaceTime, social media, and online discussion forums. To communicate with healthcare providers, most were willing to use text messaging and had not, but desired to use Skype/FaceTime. Fewer were willing to use social media or online discussion forums due to concerns about privacy and security. Most were willing to use text messaging, Skype/FaceTime, or online discussion forums to support health in other ways, but few had done so. About half were willing to use automated phone calls, but most did not like them due to the impersonal nature and time required. Developers should consider such preferences in design of health information technologies.

Health information technology in ambulatory care in a developing country

Background

Physicians need to apply new technologies in ambulatory care. At present, with regard to the extended use of information technology in other departments in Iran it has yet to be considerably developed by physicians and clinical technicians in the health department.

Objective

To determine the rate of use of health information technology in the clinics of specialist- and subspecialist physicians in Semnan city, Iran.

Methods

This was a 2016 cross-sectional study conducted in physicians’ offices of Semnan city in Iran. All physicians’ offices in Semnan (130) were studied in this research. A researcher made and Likert-type questionnaire was designed, and consisted of two sections: the first section included demographic items and the second section consisted of four subscales (telemedicine, patient’s safety, electronic patient record, and electronic communications). In order to determine the validity, the primary questionnaire was reviewed by one medical informatics- and two health information management experts from Semnan University of Medical Sciences. Utilizing the experts’ suggestions, the questionnaire was rewritten and became more focused. Then the questionnaire was piloted on forty participants, randomly selected from different physicians’ offices. Participants in the pilot study were excluded from the study. Cronbach’s alpha was used to calculate the reliability of the instruments. Finally, SPSS version 16 was used to conduct descriptive and inferential statistics.

Results

The minimum mean related to the physicians’ use of E-mail services for the purpose of communicating with the patients, the physicians’ use of computer-aided diagnostics to diagnose the patients’ illnesses, and the level of the physicians’ access to the electronic medical record of patients in the other treatment centers were 2.01, 3.58, and 1.43 respectively. The maximum mean score was related to the physicians’ use of social networks to communicate with other physicians (3.64). The study showed that the physicians used less computerized systems in their clinic for the purpose of managing their patients’ safety and there was a significant difference between the mean of the scores (p<0.001)

Conclusion

The results showed that the physicians used some aspects of health information technology for the reduction of medical risks and increase of the patient’s safety, by collecting the medical data of patients and the rapid and apropos recovering of them for adaptation of clinical decisions.

Ethical implications of digital communication for the patient-clinician relationship: analysis of interviews with clinicians and young adults with long term conditions (the LYNC study)

BACKGROUND

Digital communication between a patient and their clinician offers the potential for improved patient care, particularly for young people with long term conditions who are at risk of service disengagement. However, its use raises a number of ethical questions which have not been explored in empirical studies. The objective of this study was to examine, from the patient and clinician perspective, the ethical implications of the use of digital clinical communication in the context of young people living with long-term conditions.

METHODS

A total of 129 semi-structured interviews, 59 with young people and 70 with healthcare professionals, from 20 United Kingdom (UK)-based specialist clinics were conducted as part of the LYNC study. Transcripts from five sites (cancer, liver, renal, cystic fibrosis and mental health) were read by a core team to identify explicit and implicit ethical issues and develop descriptive ethical codes. Our subsequent thematic analysis was developed iteratively with reference to professional and ethical norms.

RESULTS

Clinician participants saw digital clinical communication as potentially increasing patient empowerment and autonomy; improving trust between patient and healthcare professional; and reducing harm because of rapid access to clinical advice. However, they also described ethical challenges, including: difficulty with defining and maintaining boundaries of confidentiality; uncertainty regarding the level of consent required; and blurring of the limits of a clinician's duty of care when unlimited access is possible. Paradoxically, the use of digital clinical communication can create dependence rather than promote autonomy in some patients. Patient participants varied in their understanding of, and concern about, confidentiality in the context of digital communication. An overarching theme emerging from the data was a shifting of the boundaries of the patient-clinician relationship and the professional duty of care in the context of use of clinical digital communication.

CONCLUSIONS

The ethical implications of clinical digital communication are complex and go beyond concerns about confidentiality and consent. Any development of this form of communication should consider its impact on the patient-clinician-relationship, and include appropriate safeguards to ensure that professional ethical obligations are adhered to.

Patients' Perceptions of Applying Information and Communication Technology Tools in Self-care and Factors Affecting It

Introduction:

In recent years patient self-care has emerged as an important component of disease management programs. The ICT tools facilitate the self-care process with improved access to information resources, effective communication between patients and healthcare professionals, and social support services.

Aim:

The purpose of this study was identifying the perception of patients from the application of information communication technology in self-care in educational centers of Urmia University of Medical Sciences.

Material and Methods:

This is a descriptive cross-sectional study conducted in 2018. The studied population consisted 540 hospitalized patients from educational hospitals affiliated to Urmia university of medical sciences. For data collection, a self-designed questionnaire was developed which valid and reliable instrument to be measured. The statistical analysis of data was done using the SPSS Software.

Results:

more patients’ interest to use of ICT tools in case of social media (34%), computer-based (25%) and the most common applications ICT tools included patient education (34%) and searching health information (23%). The most factors effective in the usage of ICT tools by patients were related to ease of using ICT tools (4.82), ICT tools reliability (4.73) and design ICT tools based on patient needs and preferences (4.68) respectively.

Conclusion:

The ICT tools are critical to patient self- care. To encourage more ICT adoption, patients should be made aware of the benefits of ICT and active involvement in the process of technology development. It seems necessary; ICT tools should be designed user-friendly, easy to use, reliable and usable.

Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England

OBJECTIVES

Evaluation of a pilot study of an online consultation system in primary care. We describe who used the system, when and why, and the National Health Service costs associated with its use.

DESIGN

15-month observational study.

SETTING

Primary care practices in South West England.

RESULTS

36 General practices covering 396 828 patients took part in the pilot. The online consultation website was viewed 35 981 times over the pilot period (mean 9.11 visits per 1000 patients per month). 7472 patients went on to complete an 'e-consultation' (mean 2.00 online consultations per 1000 patients per month). E-consultations were mainly performed on weekdays and during normal working hours. Patient records (n=485) were abstracted for eight practices and showed that women were more likely to use e-consultations than men (64.7% vs 35.3%) and users had a median age of 39 years (IQR 30-50). The most common reason for an e-consultation was an administrative request (eg, test results, letters and repeat prescriptions (22.5%)) followed by infections/immunological issues (14.4%). The majority of patients (65.2%) received a response within 2 days. The most common outcome was a face-to-face (38%) or telephone consultation (32%). The former were more often needed for patients consulting about new conditions (OR 1.56, 95% CI 1.05 to 2.27, p=0.049). The average cost of a practice's response to an e-consultation was £36.28, primarily triage time and resulting face-to-face/telephone consultations needed.

CONCLUSIONS

Use of e-consultations is very low, particularly at weekends. Unless this can be improved, any impact on staff workload and patient waiting times is likely to be negligible. It is possible that use of e-consultations increases primary care workload and costs. Online consultation systems could be developed to improve efficiency both for staff and patients. These findings have implications for software developers as well as primary care services and policy-makers who are considering investing in online consultation systems.

Email communication in a developing country: different family physician and patient perspectives

BACKGROUND

Email communication between physicians and patients could improve access to and delivery of health care. Most of the literature studies about email communication between physicians and patients have been conducted in developing countries. Therefore, this study aims to analyze the practices, attitudes, and barriers of both physicians' and patients' use of email within the same health care setting of a developing country.

METHODS

A cross-sectional paper-based survey was conducted among 39 physicians and 500 patients at the Family Medicine clinics of the American University of Beirut, a tertiary academic medical center.

RESULTS

Most of the surveyed patients and physicians reported that they would like to communicate through email and agreed that it is useful. However, only 19% of the patients have ever communicated with their physicians via email, and only 5.1% of physicians have often communicated with their patients via email. Almost half of the patients surveyed were unaware of the possibility of this form of communication, and only 17% reported that their physician offered them his or her email address. In addition, physicians and patients did not agree on the services to be provided by email communication. For instance, almost half of the patients indicated consultation for an urgent medical matter as suitable for email communication.

CONCLUSION

The use of email communication in health care is still scarce. Patients and physicians have different perspectives of its use and importance. Further rigorous research is needed to clarify the advantages and disadvantages of this form of communication, especially in the developing world. Interested physicians are encouraged to establish appropriate personal policies for email communication with adequate announcement and patient education plans.

Use of email, cell phone and text message between patients and primary-care physicians: cross-sectional study in a French-speaking part of Switzerland

Background

Physicians’ daily work is increasingly affected by the use of emails, text messages and cell phone calls with their patients. The aim of this study was to describe their use between primary-care physicians and patients in a French-speaking part of Switzerland.

Methods

A cross-sectional mail survey was conducted among all primary-care physicians of Geneva canton (n = 636). The questionnaire focused on the frequency of giving access to, type of use, advantages and disadvantages of email, cell phone calls and text messages communication between physicians and patients.

Results

Six hundred thirty-six questionnaires were mailed, 412 (65 %) were returned and 372 (58 %) could be analysed (37 refusals and three blanks). Seventy-two percent physicians gave their email-address and 74 % their cell phone number to their patients. Emails were used to respond to patients’ questions (82 %) and change appointments (72 %) while cell phone calls and text messages were used to follow patients’ health conditions. Sixty-four percent of those who used email communication never discussed the rules for email exchanges, and 54 % did not address confidentiality issues with their patients. Most commonly identified advantages of emails, cell phone calls and text messages were improved relationship with the patient, saving time (for emails) and improving the follow-up (for cell phone and text messages). The main disadvantages included misuse by the patient, interference with private life and lack of reimbursement.

Conclusions

These tools are widely used by primary-care physicians with their patients. More attention should be paid to confidentiality, documentation and reimbursement when using email communication in order to optimize its use.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1776-9) contains supplementary material, which is available to authorized users.

Patient-to-physician messaging: volume nearly tripled as more patients joined system, but per capita rate plateaued

Patients want to be able to communicate with their physicians by e-mail. However, physicians are often concerned about the impact that such communications will have on their time, productivity, and reimbursement. Typically, physicians are not reimbursed for time spent communicating with patients electronically. But under federal meaningful-use criteria for information technology, physicians can receive a modest incentive for such communications. Little is known about trends in secure e-mail messaging between physicians and patients. To understand these trends, we analyzed the volume of messages in a large academic health system's patient portal in the period 2001-10. At the end of 2010, 49,778 patients (22.7 percent of all patients seen within the system) had enrolled in the portal, and 36.9 percent of enrolled patients (8.4 percent of all patients) had sent at least one message to a physician. Physicians in the aggregate saw a near tripling of e-mail messages during the study period. However, the number of messages per hundred patients per month stabilized between 2005 and 2010, at an average of 18.9 messages. As physician reimbursement moves toward global payments, physicians' and patients' participation in secure messaging will likely increase, and electronic communication should be considered part of physicians' job descriptions.

EHealth Technologies in Inflammatory Bowel Disease: A Systematic Review

BACKGROUND AND AIMS

Electronic-health technologies (eHealth) such as Web-based interventions, virtual clinics, smart-phone applications, and telemedicine are being used to manage patients with inflammatory bowel disease (IBD). We aimed to: (1) Evaluate the impact of eHealth technologies on conventional clinical indices and patient-reported outcome measures (PROs) in IBD; (2) assess the effectiveness, cost-effectiveness and feasibility of using eHealth technologies to facilitate the self-management of individuals with IBD, and; (3) provide recommendations for their design and optimal use for patient care.

METHODS

Relevant publications were identified via a literature search, and 17 publications were selected based on predefined quality parameters.

RESULTS

Six randomized controlled trials and nine observational studies utilizing eHealth technologies in IBD were identified. Compared with standard outpatient-led care, eHealth technologies have led to improvements in: Relapse duration [(n = 1) 18 days vs 77 days, p < 0.001]; disease activity (n = 2); short-term medication adherence (n = 3); quality of life (n = 4); IBD knowledge (n = 2); healthcare costs (n = 4); the number of acute visits to the outpatient clinic due to IBD symptoms (n = 1), and; facilitating the remote management of up to 20% of an IBD cohort (n = 2). Methodological shortcomings of eHealth studies include heterogeneity of outcome measures, lack of clinician/patient input, lack of validation against conventional clinical indices and PROs, and limited cost-benefit analyses.

CONCLUSIONS

EHealth technologies have the potential for promoting self-management and reducing the impact of the growing burden of IBD on health care resource utilization. A theoretical framework should be applied to the development, implementation, and evaluation of eHealth interventions.

Electronic mail communication between physicians and patients: a review of challenges and opportunities

Although promising benefits hold for email communication between physicians and patients in terms of lowering the costs of health care while maintaining or improving the quality of disease management and health promotion, physician use of email with patients is still low and lags behind the willingness of patients to communicate with their physicians through email. There is also a discrepancy between physicians' willingness and actual practice of email communication. Several factors may explain these discrepancies. They include physicians differ in their experience and attitude towards information technology; some may not be convinced that patients appreciate, need and can communicate by email with their doctors; others are still waiting for robust evidence on service performance and efficiency in addition to patient satisfaction and outcome that support such practice; and many are reluctant to do so because of perceived barriers. This report is a review of the literature on the readiness for and adoption of physician-patient email communication, and how can challenges be or have been addressed. The need for Governmental support and directives for email communication to move forward is iterated, and opportunities for future research are pointed out.

Patients' Online Access to Their Primary Care Electronic Health Records and Linked Online Services: Implications for Research and Practice

Online access to medical records and linked services, including requesting repeat prescriptions and booking appointments, enables patients to personalize their access to care. However, online access creates opportunities and challenges for both health professionals and their patients, in practices and in research. The challenges for practice are the impact of online services on workload and the quality and safety of health care. Health professionals are concerned about the impact on workload, especially from email or other online enquiry systems, as well as risks to privacy. Patients report how online access provides a convenient means through which to access their health provider and may offer greater satisfaction if they get a timely response from a clinician. Online access and services may also result in unforeseen consequences and may change the nature of the patient-clinician interaction. Research challenges include: (1) Ensuring privacy, including how to control inappropriate carer and guardian access to medical records; (2) Whether online access to records improves patient safety and health outcomes; (3) Whether record access increases disparities across social classes and between genders; and (4) Improving efficiency. The challenges for practice are: (1) How to incorporate online access into clinical workflow; (2) The need for a business model to fund the additional time taken. Creating a sustainable business model for a safe, private, informative, more equitable online service is needed if online access to records is to be provided outside of pay-for-service systems.

A Mixed-Methods Study of Patient-Provider E-Mail Content in a Safety-Net Setting

To explore the content of patient-provider e-mails in a safety-net primary care clinic, we conducted a content analysis using inductive and deductive coding of e-mail exchanges (n = 31) collected from January through November 2013. Participants were English-speaking adult patients with a chronic condition (or their caregivers) cared for at a single publicly funded general internal medicine clinic and their primary care providers (attending general internist physicians, clinical fellows, internal medicine residents, and nurse practitioners). All e-mails were nonurgent. Patients included a medical update in 19% of all e-mails. Patients requested action in 77% of e-mails, and the most common requests overall were for action regarding medications or treatment (29%). Requests for information were less common (45% of e-mails). Patient requests (n = 56) were resolved in 84% of e-mail exchanges, resulting in 63 actions. These results show that patients in safety-net clinics are capable of safely and effectively using electronic messaging for between-visit communication with providers. Safety-net systems should implement electronic communications tools as soon as possible to increase health care access and enhance patients' involvement in their care.

Performance improvement indicators of the Medical Records Department and Information Technology (IT) in hospitals

Medical Record Department (MRD) has a vital role in making short and long term plans to improve health system services. The aim of this study was to describe performance improvement indicators of hospital MRD and information technology (IT).

Rapid growth in surgeons' use of secure messaging in a patient portal

BACKGROUND

Use of secure messaging through patient portals has risen substantially in recent years due to provider incentives and consumer demand. Secure messaging may increase patient satisfaction and improve outcomes, but also adds to physician workload. Most prior studies of secure messaging focused on primary care and medical specialties. We examined surgeons' use of secure messaging and the contribution of messaging to outpatient interactions in a broadly deployed patient portal.

METHODS

We determined the number of clinic visits and secure messages for surgical providers in the first 3 years (2008-2010) after patient portal deployment at an academic medical center. We calculated the proportion of outpatient interaction conducted through messaging for each specialty. Logistic regression models compared the likelihood of message-based versus clinic outpatient interaction across surgical specialties.

RESULTS

Over the study period, surgical providers delivered care in 648,200 clinic visits and received 83,912 messages, with more than 200% growth in monthly message volume. Surgical specialties receiving the most messages were orthopedics/podiatry (25.1%), otolaryngology (20.1%), urology (10.8%), and general surgery (9.6%); vascular surgery (0.8%) and pediatric general surgery (0.2%) received the fewest. The proportion of outpatient interactions conducted through secure messaging increased significantly from 5.4% in 2008 to 15.3% in 2010 (p < 0.001) with all specialties experiencing growth. Heart/lung transplantation (74.9%), liver/kidney/pancreas transplantation (69.5%), and general surgery (48.7%) had the highest proportion of message-based outpatient interaction by the end of the study.

CONCLUSIONS

This study demonstrates rapid adoption of online secure messaging across surgical specialties with significant growth in its use for outpatient interaction. Some specialties, particularly those with long-term follow-up, interacted with patients more through secure messaging than in person. As surgeons devote more time to secure messaging, additional research will be needed to understand the care delivered through online interactions and to develop models for reimbursement.

Email for clinical communication between healthcare professionals

BACKGROUND

Email is one of the most widely used methods of communication, but its use in healthcare is still uncommon. Where email communication has been utilised in health care, its purposes have included clinical communication between healthcare professionals, but the effects of using email in this way are not well known. We updated a 2012 review of the use of email for two-way clinical communication between healthcare professionals.

OBJECTIVES

To assess the effects of email for clinical communication between healthcare professionals on healthcare professional outcomes, patient outcomes, health service performance, and service efficiency and acceptability, when compared to other forms of communicating clinical information.

SEARCH METHODS

We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9 2013), MEDLINE (OvidSP) (1946 to August 2013), EMBASE (OvidSP) (1974 to August 2013), PsycINFO (1967 to August 2013), CINAHL (EbscoHOST) (1982 to August 2013), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched November 2013). We used additional search methods: examining reference lists and contacting authors.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised trials, controlled before and after studies, and interrupted time series studies examining interventions in which healthcare professionals used email for communicating clinical information in the form of: 1) unsecured email, 2) secure email, or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion, assessed the included studies' risk of bias, and extracted data. We contacted study authors for additional information and have reported all measures as per the study report.

MAIN RESULTS

The previous version of this review included one randomised controlled trial involving 327 patients and 159 healthcare providers at baseline. It compared an email to physicians containing patient-specific osteoporosis risk information and guidelines for evaluation and treatment versus usual care (no email). This study was at high risk of bias for the allocation concealment and blinding domains. The email reminder changed health professional actions significantly, with professionals more likely to provide guideline-recommended osteoporosis treatment (bone density measurement or osteoporosis medication, or both) when compared with usual care. The evidence for its impact on patient behaviours or actions was inconclusive. One measure found that the electronic medical reminder message impacted patient behaviour positively (patients had a higher calcium intake), and two found no difference between the two groups. The study did not assess health service outcomes or harms.No new studies were identified for this update.

AUTHORS' CONCLUSIONS

Only one study was identified for inclusion, providing insufficient evidence for guiding clinical practice in regard to the use of email for clinical communication between healthcare professionals. Future research should aim to utilise high-quality study designs that use the most recent developments in information technology, with consideration of the complexity of email as an intervention.

You've got mail … and need follow-up: the effect and patient perception of e-mail follow-up reminders after emergency department discharge

OBJECTIVES

The hypothesis was that a reminder about recommended primary care physician (PCP) follow-up, sent via e-mail to patients discharged from the emergency department (ED), would increase the proportion of patients who followed up with their PCPs within the recommended time frame. Patient receptiveness to e-mail follow-up reminders was also assessed.

METHODS

This was a mixed methods clinical intervention study with subjects randomized either to receive the usual care discharge instructions only or to also receive a reminder e-mail message the day after the ED visit. The reminder e-mail contained the subject's PCP's name and address and the recommended PCP follow-up time interval. A blinded review of outpatient PCP medical records was conducted to determine whether and when follow-up occurred. Researchers attempted to contact patients with a telephone survey 2 weeks after their ED visits. The primary outcomes between groups were compared using chi-square tests and relative risks (RRs) with 95% confidence intervals (CIs).

RESULTS

Thirty-three percent of the intervention group and 32% of the control group followed-up as recommended (RR = 1.04, 95% CI = 0.81 to 1.33); 52% of the intervention group and 48% of the control group followed-up within 10 days of the recommended time (RR = 1.08, 95% CI = 0.91 to 1.29). The 334 patients (57%) successfully contacted via telephone demonstrated a high interest in receiving future e-mail reminders (75%), with the group that received e-mail reminders more likely to want one in the future than those who did not receive e-mail reminders (82.5% vs. 69.76%; p = 0.04).

CONCLUSIONS

E-mail reminders sent after ED visits did not improve patients' adherence to the recommended timing of primary care follow-up contained in discharge instructions. Subjects in both the control and the intervention groups favorably viewed the concept of e-mail reminders, suggesting that the value of e-mail reminders after ED discharge may be in areas such as patient satisfaction that were not specifically targeted for measurement in this study.

Patients' online access to their electronic health records and linked online services: a systematic interpretative review

OBJECTIVES

To investigate the effect of providing patients online access to their electronic health record (EHR) and linked transactional services on the provision, quality and safety of healthcare. The objectives are also to identify and understand: barriers and facilitators for providing online access to their records and services for primary care workers; and their association with organisational/IT system issues.

SETTING

Primary care.

PARTICIPANTS

A total of 143 studies were included. 17 were experimental in design and subject to risk of bias assessment, which is reported in a separate paper. Detailed inclusion and exclusion criteria have also been published elsewhere in the protocol.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome measure was change in quality or safety as a result of implementation or utilisation of online records/transactional services.

RESULTS

No studies reported changes in health outcomes; though eight detected medication errors and seven reported improved uptake of preventative care. Professional concerns over privacy were reported in 14 studies. 18 studies reported concern over potential increased workload; with some showing an increase workload in email or online messaging; telephone contact remaining unchanged, and face-to face contact staying the same or falling. Owing to heterogeneity in reporting overall workload change was hard to predict. 10 studies reported how online access offered convenience, primarily for more advantaged patients, who were largely highly satisfied with the process when clinician responses were prompt.

CONCLUSIONS

Patient online access and services offer increased convenience and satisfaction. However, professionals were concerned about impact on workload and risk to privacy. Studies correcting medication errors may improve patient safety. There may need to be a redesign of the business process to engage health professionals in online access and of the EHR to make it friendlier and provide equity of access to a wider group of patients. A1 SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42012003091.

Online medicine for pregnant women

Objective. To assess the use of cell phones and email as means of communication between pregnant women and their gynecologists and family physicians. Study Design. A cross-sectional study of pregnant women at routine followup. One hundred and twenty women participated in the study. Results. The mean age was 27.4 ± 3.4 years. One hundred nineteen women owned a cell phone and 114 (95%) had an email address. Seventy-two women (60%) had their gynecologist's cell phone number and 50 women (42%) had their family physician's cell phone number. More women contacted their gynecologist via cell phone or email during pregnancy compared to their family physician (P = 0.005 and 0.009, resp.). Most preferred to communicate with their physician via cell phone at predetermined times, but by email at any time during the day (P < 0.0001). They would use cell phones for emergencies or unusual problems but preferred email for other matters (P < 0.0001). Conclusions. Pregnant women in the Negev region do not have a preference between the use of cell phones or email for medical consultation with their gynecologist or family physician. The provision of the physician's cell phone numbers or email address together with the provision of guidelines and resources could improve healthcare services.

What keeps family physicians busy in Portugal? A multicentre observational study of work other than direct patient contacts

OBJECTIVES

To quantify the time spent by family physicians (FP) on tasks other than direct patient contact, to evaluate job satisfaction, to analyse the association between time spent on tasks and physician characteristics, the association between the number of tasks performed and physician characteristics and the association between time spent on tasks and job satisfaction.

DESIGN

Cross-sectional, using time-and-motion techniques. Two workdays were documented by direct observation. A significance level of 0.05 was adopted.

SETTING

Multicentric in 104 Portuguese family practices.

PARTICIPANTS

A convenience sample of FP, with lists of over 1000 patients, teaching senior medical students and first-year family medicine residents in 2012, was obtained. Of the 217 FP invited to participate, 155 completed the study.

MAIN OUTCOMES MEASURED

Time spent on tasks other than direct patient contact and on the performance of more than one task simultaneously, the number of direct patient contacts in the office, the number of indirect patient contacts, job satisfaction, demographic and professional characteristics associated with time spent on tasks and the number of different tasks performed, and the association between time spent on tasks and job satisfaction.

RESULTS

FP (n=155) spent a mean of 143.6 min/day (95% CI 135.2 to 152.0) performing tasks such as prescription refills, teaching, meetings, management and communication with other professionals (33.4% of their workload). FP with larger patient lists spent less time on these tasks (p=0.002). Older FP (p=0.021) and those with larger lists (p=0.011) performed fewer tasks. The mean job satisfaction score was 3.5 (out of 5). No association was found between job satisfaction and time spent on tasks.

CONCLUSIONS

FP spent one-third of their workday in coordinating care, teaching and managing. Time devoted to these tasks decreases with increasing list size and physician age.

E-mail communication in the management of gastroenterology patients: a review

E-mail correspondence between physicians and patients can be a useful tool to improve communication efficiency, provide economic and ecological benefits, improve therapeutic interventions and adherence, and enhance self-management. The model of self-management in chronic disease has become an integral component of North American and British medicine. From a practical standpoint, the use of e-mail between physicians and patients can complement the self-management model. E-mail communication has many benefits from both patient and physician perspectives. E-mail contact reduces the inefficiencies associated with telecommunications. Physicians are able to better document out-of-office patient encounters and provide access to specialist care for patients in remote locations. This use of e-mail has the potential to increase patient safety through physician approval of self-manager actions, including earlier initiation of needed treatments. Fewer clinic visits afford additional time for new consultations and sicker patients, reducing the overall burden on referral and wait times. The present article reviews some of the literature regarding physician-patient e-mail communication in the general ambulatory setting, in the context of chronic disease and with a specific focus on inflammatory bowel disease (IBD). The authors provide a framework for the use of e-mail communication in the IBD population, with emphasis on the concept of e-mail use. Also illustrated are the benefits and disadvantages, and examples of the e-mail contract as proposed by the Canadian Medical Protective Association. Examples of specific e-mail communication topics are provided for several IBD scenarios. Potential negative consequences of this mode of communication are also discussed.

Aligning medication reconciliation and secure messaging: qualitative study of primary care providers' perspectives

BACKGROUND

Virtual (non-face-to-face) medication reconciliation strategies may reduce adverse drug events (ADEs) among vulnerable ambulatory patients. Understanding provider perspectives on the use of technology for medication reconciliation can inform the design of patient-centered solutions to improve ambulatory medication safety.

OBJECTIVE

The aim of the study was to describe primary care providers' experiences of ambulatory medication reconciliation and secure messaging (secure email between patients and providers), and to elicit perceptions of a virtual medication reconciliation system using secure messaging (SM).

METHODS

This was a qualitative study using semi-structured interviews. From January 2012 to May 2012, we conducted structured observations of primary care clinical activities and interviewed 15 primary care providers within a Veterans Affairs Healthcare System in Boston, Massachusetts (USA). We carried out content analysis informed by the grounded theory.

RESULTS

Of the 15 participating providers, 12 were female and 11 saw 10 or fewer patients in a typical workday. Experiences and perceptions elicited from providers during in-depth interviews were organized into 12 overarching themes: 4 themes for experiences with medication reconciliation, 3 themes for perceptions on how to improve ambulatory medication reconciliation, and 5 themes for experiences with SM. Providers generally recognized medication reconciliation as a valuable component of primary care delivery and all agreed that medication reconciliation following hospital discharge is a key priority. Most providers favored delegating the responsibility for medication reconciliation to another member of the staff, such as a nurse or a pharmacist. The 4 themes related to ambulatory medication reconciliation were (1) the approach to complex patients, (2) the effectiveness of medication reconciliation in preventing ADEs, (3) challenges to completing medication reconciliation, and (4) medication reconciliation during transitions of care. Specifically, providers emphasized the importance of medication reconciliation at the post-hospital visit. Providers indicated that assistance from a caregiver (eg, a family member) for medication reconciliation was helpful for complex or elderly patients and that patients' social or cognitive factors often made medication reconciliation challenging. Regarding providers' use of SM, about half reported using SM frequently, but all felt that it improved their clinical workflow and nearly all providers were enthusiastic about a virtual medication reconciliation system, such as one using SM. All providers thought that such a system could reduce ADEs.

CONCLUSIONS

Although providers recognize the importance and value of ambulatory medication reconciliation, various factors make it difficult to execute this task effectively, particularly among complex or elderly patients and patients with complicated social circumstances. Many providers favor enlisting the support of pharmacists or nurses to perform medication reconciliation in the outpatient setting. In general, providers are enthusiastic about the prospect of using secure messaging for medication reconciliation, particularly during transitions of care, and believe a system of virtual medication reconciliation could reduce ADEs.

Pediatric caregiver attitudes toward email communication: survey in an urban primary care setting

Background

Overall usage of email communication between patients and physicians continues to increase, due in part to expanding the adoption of electronic health records and patient portals. Unequal access and acceptance of these technologies has the potential to exacerbate disparities in care. Little is known about the attitudes of pediatric caregivers with regard to their acceptance of email as a means to communicate with their health care providers.

Objective

We conducted a survey to assess pediatric caregiver access to and attitudes toward the use of electronic communication modalities to communicate with health care providers in an urban pediatric primary care clinic.

Methods

Participants were pediatric caregivers recruited from an urban pediatric primary care clinic in Baltimore, Maryland, who completed a 35-item questionnaire in this cross-sectional study.

Results

Of the 229 caregivers who completed the survey (91.2% response rate), 171 (74.6%) reported that they use email to communicate with others. Of the email users, 145 respondents (86.3%) stated that they would like to email doctors, although only 18 (10.7%) actually do so. Among email users, African-American caregivers were much less likely to support the expanded use of email communication with health care providers (adjusted OR 0.34, 95% CI 0.14-0.82) as were those with annual incomes less than US $30,000 (adjusted OR 0.26, 95% CI 0.09-0.74).

Conclusions

Caregivers of children have access to email and many would be interested in communicating with health care providers. However, African-Americans and those in lower socioeconomic groups were much less likely to have positive attitudes toward email.

What parents want from emails with their pediatrician: implications for teaching communication skills

OBJECTIVE

Physician-patient email communication is increasing but trainees receive no education on this communication medium. Research eliciting patient preferences about email communication could inform training. Investigators elicited parents' perspectives on physician-parent email communication and compared parent and faculty assessments of medical students' emails.

METHODS

This mixed methods study explored physician-parent email communication in 5 parent focus groups using qualitative analyses to identify themes. Differences between faculty and parent assessment scores for students' email responses were calculated using univariate general linear modeling.

RESULTS

Themes that emerged were: (1) Building the Relationship, (2) Clarity of Communication and (3) Expectations. Parents criticized student's statements as condescending. The sum of assessment scores by parents and faculty were moderately correlated (r(44)=.407, P<.01), but parents gave students lower scores on "acknowledges validity/expresses empathy" (P=.01) and higher scores on "provides next steps" (P<.01) and "identifies issues" (P<.01).

CONCLUSION

Parents place value on students' abilities to communicate clearly and convey respect and empathy in email. Parent and faculty perspectives on email communication are similar but not the same.

PRACTICE IMPLICATIONS

Differences between parental and faculty assessments of medical students' emails supports the need for the involvement of patients and families in email communication curriculum development.

Patient portal implementation: resident and attending physician attitudes

BACKGROUND AND OBJECTIVES

Electronic patient portals are increasingly common, but there is little information regarding attitudes of faculty and residents at academic medical centers toward them.

METHODS

The primary objective was to investigate attitudes toward electronic patient portals among primary care residents and faculty and changes in faculty attitudes after implementation. The study design included a pre-implementation survey of 39 general internal medicine and family medicine residents and 43 generalist faculty addressing attitudes and expectations of a planned patient portal and also a pre- and post-implementation survey of general internal medicine and family medicine faculty physicians. The survey also addressed email communication with patients.

RESULTS

Prior to portal implementation, residents reported receiving much less e-mail from patients than faculty physicians; 68% and 9% of residents and faculty, respectively, reported no email exchange in a typical month. Residents were less likely to agree with allowing patients to view selected parts of their medical record on-line than faculty physicians (57% and 81%, respectively). Physicians who participated in the portal's pilot implementation had expected workload to increase (64% agreed), but after implementation, 87% of those responding were neutral or disagreed that workload had increased. After implementation, only 33% believed quality of care had improved compared to 55% who had expected it to improve prior to implementation.

CONCLUSIONS

Residents and faculty physicians need to be prepared for a changing environment of electronic communication with patients. Some positive and negative expectations of physicians toward enhanced electronic access by patients were not borne out by experience.

Physician e-mail and telephone contact after emergency department visit improves patient satisfaction: a crossover trial

STUDY OBJECTIVE

Enhancing emergency department (ED) patient satisfaction has wide-ranging benefits. We seek to determine how postvisit patient-physician contact by e-mail or telephone affects patients' satisfaction with their emergency physician.

METHODS

We undertook this crossover study from May 1, 2010, to June 30, 2010, at 2 community EDs. Forty-two physicians either e-mailed or telephoned their patients within 72 hours of the ED visit for 1 month; in the alternate month, they provided no contact, serving as their own controls. Patients received satisfaction surveys after their ED visit. Patient satisfaction is reported as a percentage of those responding very good or excellent on a 5-point Likert scale for 3 questions about their emergency physician's skills, care, and communication. We calculated differences between patient groups (noncontact versus contact) using an intention-to-treat analysis.

RESULTS

The mean patient satisfaction score was 79.4% for the 1,002 patients in the noncontact group and 87.7% for the 348 patients in the contact group (difference 8.3%; 95% confidence interval 4.0% to 12.6%). Patient satisfaction scores were similar for e-mail and telephone contact: 89.3% for the e-mail group and 85.2% for the telephone group (difference 4.1%; 95% confidence interval -2.3% to 10.5%).

CONCLUSION

Patient satisfaction was higher when emergency physicians contacted patients briefly after their visit, either by e-mail or by telephone. Higher patient satisfaction was observed equally among patients contacted by e-mail and those contacted by telephone. Postvisit patient-physician contact could be a valuable practice to improve ED patient satisfaction.

Email for the provision of information on disease prevention and health promotion

BACKGROUND

Email is a popular and commonly used method of communication, but its use in health care is not routine. Its application in health care has included the provision of information on disease prevention and health promotion, but the effects of using email in this way are not known. This review assesses the use of email for the provision of information on disease prevention and health promotion.

OBJECTIVES

To assess the effects of email for the provision of information on disease prevention and health promotion, compared to standard mail or usual care, on outcomes for healthcare professionals, patients and caregivers, and health services, including harms.

SEARCH METHODS

We searched: the Cochrane Consumers and Communication Review Group Specialised Register (January 2010), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (1950 to January 2010), EMBASE (1980 to January 2010), CINAHL (1982 to February 2010), ERIC (1965 to January 2010) and PsycINFO (1967 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists, contacting authors.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies examining interventions where email is used by healthcare professionals to provide information to patients on disease prevention and health promotion, and taking the form of 1) unsecured email 2) secure email or 3) web messaging. We considered healthcare professionals or associated administrative staff as participants originating the email communication, and patients and caregivers as participants receiving the email communication, in all settings. Email communication was one-way from healthcare professionals or associated administrative staff originating the email communication, to patients or caregivers receiving the email communication.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of included studies and extracted data. We contacted study authors for additional information. We assessed risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. For continuous outcome measures, we report effect sizes as mean differences (MDs). For dichotomous outcome measures, we report effect sizes as odds ratios (ORs). We conducted a meta-analysis for one primary health service outcome, comparing email communication to standard mail, and report this result as an OR.

MAIN RESULTS

We included six randomised controlled trials involving 8372 people. All trials were judged to be at high risk of bias for at least one domain. Four trials compared email communication to standard mail and two compared email communication to usual care. For the primary health service outcome of uptake of preventive screening, there was no difference between email and standard mail (OR 0.93; 95% CI 0.69 to 1.24). For both comparisons (email versus standard mail and email versus usual care) there was no difference between the groups for patient or caregiver understanding and support. Results were inconclusive for patient or caregiver behaviours and actions. For email versus usual care only, there was no significant difference between groups for the primary outcome of patient health status and well-being. No data were reported relating to healthcare professionals or harms.

AUTHORS' CONCLUSIONS

The evidence on the use of email for the provision of information on disease prevention and health promotion was weak, and therefore inadequate to inform clinical practice. The available trials mostly provide inconclusive, or no evidence for the outcomes of interest in this review. Future research needs to use high-quality study designs that take advantage of the most recent developments in information technology, with consideration of the complexity of email as an intervention.

Email for clinical communication between patients/caregivers and healthcare professionals

BACKGROUND

Email is a popular and commonly-used method of communication, but its use in health care is not routine. Where email communication has been demonstrated in health care this has included its use for communication between patients/caregivers and healthcare professionals for clinical purposes, but the effects of using email in this way is not known.This review addresses the use of email for two-way clinical communication between patients/caregivers and healthcare professionals.

OBJECTIVES

To assess the effects of healthcare professionals and patients using email to communicate with each other, on patient outcomes, health service performance, service efficiency and acceptability.

SEARCH METHODS

We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO (OvidSP) (1967 to January 2010), CINAHL (EbscoHOST) (1982 to February 2010) and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists, contacting authors.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies examining interventions using email to allow patients to communicate clinical concerns to a healthcare professional and receive a reply, and taking the form of 1) unsecured email 2) secure email or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of included studies and extracted data. We contacted study authors for additional information. We assessed risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. For continuous measures, we report effect sizes as mean differences (MD). For dichotomous outcome measures, we report effect sizes as odds ratios and rate ratios. Where it was not possible to calculate an effect estimate we report mean values for both intervention and control groups and the total number of participants in each group. Where data are available only as median values it is presented as such. It was not possible to carry out any meta-analysis of the data.

MAIN RESULTS

We included nine trials enrolling 1733 patients; all trials were judged to be at risk of bias. Seven were randomised controlled trials; two were cluster-randomised controlled designs. Eight examined email as compared to standard methods of communication. One compared email with telephone for the delivery of counselling. When email was compared to standard methods, for the majority of patient/caregiver outcomes it was not possible to adequately assess whether email had any effect. For health service use outcomes it was not possible to adequately assess whether email has any effect on resource use, but some results indicated that an email intervention leads to an increased number of emails and telephone calls being received by healthcare professionals. Three studies reported some type of adverse event but it was not clear if the adverse event had any impact on the health of the patient or the quality of health care. When email counselling was compared to telephone counselling only patient outcomes were measured, and for the majority of measures there was no difference between groups. Where there were differences these showed that telephone counselling leads to greater change in lifestyle modification factors than email counselling. There was one outcome relating to harm, which showed no difference between the email and the telephone counselling groups. There were no primary outcomes relating to healthcare professionals for either comparison.

AUTHORS' CONCLUSIONS

The evidence base was found to be limited with variable results and missing data, and therefore it was not possible to adequately assess the effect of email for clinical communication between patients/caregivers and healthcare professionals. Recommendations for clinical practice could not be made. Future research should ideally address the issue of missing data and methodological concerns by adhering to published reporting standards. The rapidly changing nature of technology should be taken into account when designing and conducting future studies and barriers to trial development and implementation should also be tackled. Potential outcomes of interest for future research include cost-effectiveness and health service resource use.

Email for clinical communication between healthcare professionals

BACKGROUND

Email is a popular and commonly-used method of communication, but its use in healthcare is not routine. Where email communication has been utilised in health care, its purposes have included use for clinical communication between healthcare professionals, but the effects of using email in this way are not known. This review assesses the use of email for two-way clinical communication between healthcare professionals.

OBJECTIVES

To assess the effects of healthcare professionals using email to communicate clinical information, on healthcare professional outcomes, patient outcomes, health service performance, and service efficiency and acceptability, when compared to other forms of communicating clinical information.

SEARCH METHODS

We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO (1967 to January 2010), CINAHL (EbscoHOST) (1982 to February 2010), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists, contacting authors.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies examining interventions in which healthcare professionals used email for communicating clinical information, and that took the form of 1) unsecured email 2) secure email or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion, assessed the included studies' risk of bias, and extracted data. We contacted study authors for additional information. We report all measures as per the study report.

MAIN RESULTS

We included one randomised controlled trial involving 327 patients and 159 healthcare providers at baseline. It compared an email to physicians containing patient-specific osteoporosis risk information and guidelines for evaluation and treatment with usual care (no email). This study was at high risk of bias for the allocation concealment and blinding domains. The email reminder changed health professional actions significantly, with professionals more likely to provide guideline-recommended osteoporosis treatment (bone density measurement and/or osteoporosis medication) when compared with usual care. The evidence for its impact on patient behaviours/actions was inconclusive. One measure found that the electronic medical reminder message impacted patient behaviour positively: patients had a higher calcium intake, and two found no difference between the two groups. The study did not assess primary health service outcomes or harms.

AUTHORS' CONCLUSIONS

As only one study was identified for inclusion, the results are inadequate to inform clinical practice in regard to the use of email for clinical communication between healthcare professionals. Future research needs to use high-quality study designs that take advantage of the most recent developments in information technology, with consideration of the complexity of email as an intervention, and costs.

Providing cell phone numbers and e-mail addresses to patients: The patient's perspective, a cross sectional study

Background

Today patients can consult with their treating physician by cell phone or e-mail. These means of communication enhance the quality of medical care and increase patient satisfaction, but they can also impinge on physicians’ free time and their patient schedule while at work. The objective of this study is to assess the attitudes and practice of patients on obtaining the cell phone number or e-mail address of their physician for the purpose of medical consultation.

Methods

Personal interviews with patients, 18 years of age or above, selected by random sampling from the roster of adults insured by Clalit Health Services, Southern Division. The total response rate was 41%. The questionnaire included questions on the attitude and practice of patients towards obtaining their physician’s cell phone number or e-mail address. Comparisons were performed using Chi-square tests to analyze statistically significant differences of categorical variables. Two-tailed p values less than 0.05 were considered statistically significant, with a power of 0.8.

Results

The study sample included 200 patients with a mean age of 46.6 ± 17.1, of whom 110 were women (55%). Ninety-three (46.5%) responded that they would be very interested in obtaining their physician’s cell phone number, and an additional 83 (41.5%) would not object to obtaining it. Of the 171 patients (85.5%) who had e-mail addresses, 25 (14.6%) said they would be very interested in obtaining their physician’s e-mail address, 85 (49.7%) said they would not object to getting it, and 61 (35.7%) were not interested. In practice only one patient had requested the physician’s e-mail address and none actually had it.

Conclusions

Patients favored cell phones over e-mail for consulting with their treating physicians. With new technologies such as cell phones and e-mail in common use, it is important to determine how they can be best used and how they should be integrated into the flow of clinical practice.

Email for the coordination of healthcare appointments and attendance reminders

BACKGROUND

Email is a popular and commonly-used method of communication, but its use in health care is not routine. Where email communication has been utilised in health care, its purposes have included the coordination of healthcare appointments and attendance reminders, but the effects of using email in this way are not known. This review considers the use of email for the coordination of healthcare appointments and reminders for attendance; particularly scheduling, rescheduling and cancelling healthcare appointments, and providing prompts/reminders for attendance at appointments.

OBJECTIVES

To assess the effects of using email for the coordination of healthcare appointments and attendance reminders, compared to other forms of coordinating appointments and reminders, on outcomes for health professionals, patients and carers, and health services, including harms.

SEARCH METHODS

We searched: the Cochrane Consumers and Communication Review Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO (OvidSP) (1967 to January 2010), CINAHL (EbscoHOST) (1982 to February 2010),and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists and contacting authors.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies of interventions that use email for scheduling health appointments, for reminders for a scheduled health appointment or for ongoing coordination of health appointments and that took the form of 1) unsecured email 2) secure email or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles and abstracts of retrieved citations. No studies were identified for inclusion. Consequently, no data collection or analysis was possible.

MAIN RESULTS

No studies met the inclusion criteria, therefore there are no results to report on the use of email for the coordination of healthcare appointments and attendance reminders.

AUTHORS' CONCLUSIONS

No conclusions on the effects of using email for the coordination of healthcare appointments and attendance reminders could be made and thus no recommendations for practice can be stipulated. Given the significant theoretical opportunities that email presents, there is a need for rigorous studies addressing the review question, but this may involve addressing barriers concerning trial development and implementation.

Email for communicating results of diagnostic medical investigations to patients

BACKGROUND

As medical care becomes more complex and the ability to test for conditions grows, pressure on healthcare providers to convey increasing volumes of test results to patients is driving investigation of alternative technological solutions for their delivery. This review addresses the use of email for communicating results of diagnostic medical investigations to patients.

OBJECTIVES

To assess the effects of using email for communicating results of diagnostic medical investigations to patients, compared to SMS/ text messaging, telephone communication or usual care, on outcomes, including harms, for health professionals, patients and caregivers, and health services.

SEARCH METHODS

We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO (OvidSP) (1967 to January 2010), CINAHL (EbscoHOST) (1982 to February 2010), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists and contacting authors.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies of interventions using email for communicating results of any diagnostic medical investigations to patients, and taking the form of 1) unsecured email 2) secure email or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles and abstracts of retrieved citations. No studies were identified for inclusion. Consequently, no data collection or analysis was possible.

MAIN RESULTS

No studies met the inclusion criteria, therefore there are no results to report on the use of email for communicating results of diagnostic medical investigations to patients.

AUTHORS' CONCLUSIONS

In the absence of included studies, we can draw no conclusions on the effects of using email for communicating results of diagnostic medical investigations to patients, and thus no recommendations for practice can be stipulated. Further well-designed research should be conducted to inform practice and policy for communicating patient results via email, as this is a developing area.

Impact of electronic messaging on the patient-physician interaction

Patients are interested in secure electronic communication with their health-care providers, but physicians have been slow to adopt the technique into their practice. We have therefore reviewed the literature on secure patient messaging. Relevant studies were identified by Medline search which produced 1065 publications. Of these, 71 relevant articles were read independently by two reviewers. Currently available messaging systems allow for asynchronous communication, physician reimbursement and automated supporting functions such as triaging of patient messages and integration of messaging into medical records. The review showed that patients are satisfied with the use of secure physician messaging systems and find such services to be convenient, time-saving and useful. Physicians do not report adverse effects from their use. Legal concerns with electronic messaging include compliance with privacy standards. The economic benefits of secure messaging systems are most immediately apparent for larger health-care groups and hospitals, although smaller practices will also benefit in the long run. Secure patient-physician messaging is a convenient and useful addition to the health-care infrastructure. It can be expected that the identification of secure providers, integration with reimbursement systems and initial uptake by larger health-care organizations will speed up the adoption into routine health care.

Providing cell phone numbers and email addresses to Patients: the physician's perspective

Background

The provision of cell phone numbers and email addresses enhances the accessibility of medical consultations, but can add to the burden of physicians' routine clinical practice and affect their free time. The objective was to assess the attitudes of physicians to providing their telephone number or email address to patients.

Methods

Primary care physicians in the southern region of Israel completed a structured questionnaire that related to the study objective.

Results

The study population included 120 primary care physicians with a mean age of 41.2 ± 8.5, 88 of them women (73.3%). Physicians preferred to provide their cell phone number rather than their email address (P = 0.0007). They preferred to answer their cell phones only during the daytime and at predetermined times, but would answer email most hours of the day, including weekends and holidays (P = 0.001). More physicians (79.7%) would have preferred allotted time for email communication than allotted time for cell phone communication (50%). However, they felt that email communication was more likely to lead to miscommunication than telephone calls (P = 0.0001). There were no differences between male and female physicians on the provision of cell phone numbers or email addresses to patients. Older physicians were more prepared to provide cell phone numbers that younger ones (P = 0.039).

Conclusions

The attitude of participating physicians was to provide their cell phone number or email address to some of their patients, but most of them preferred to give out their cell phone number.

E-mail communication with patients: a survey of the American College of Physicians, Missouri Chapter

Numerous surveys have found patients expressing strong interest in e-mail communication with their physicians. However, currently very limited literature is available on physician interest. A survey was e-mailed to the members of the Missouri Chapter of the American College of Physicians to ascertain their specific concerns. Very few physicians use electronic mail with patients. Even fewer use it on a frequent basis and most do not give any written policy guidelines to patients.

Use of simulated electronic mail (e-mail) to assess medical student knowledge, professionalism, and communication skills

BACKGROUND

Physicians communicate with patients using electronic mail (e-mail) with increasing frequency. Communication skills specific to e-mail do not appear to be taught explicitly in medical school. Therefore, the effect of an instructive session on effective e-mail communication was examined.

METHOD

Four simulated e-mails from a parent were developed. Students responded to an initial e-mail and then participated in a session on effective e-mail communication. Responses to a final e-mail were assessed using a rubric with subscores for medical knowledge, communication, and professionalism.

RESULTS

Performance improved from the first to final e-mail response in the overall score and in each subscore. Improvement was sustained over the course of the academic year. Interrater reliability revealed good agreement.

CONCLUSIONS

Communicating effectively with patients via e-mail is not intuitive but can be taught. It is feasible to introduce responses to a simulated e-mail case in a clinical clerkship as an assessment tool.

E-mail in patient-provider communication: a systematic review

OBJECTIVE

To review systematically the role of e-mails in patient-provider communication in terms of e-mail content, and perspectives of providers and patients on e-mail communication in health care.

METHODS

A systematic review of studies on e-mail communication between patients and health providers in regular health care published from 2000 to 2008.

RESULTS

A total of 24 studies were included in the review. Among these studies, 21 studies examined e-mail communication between patients and providers, and three studies examined the e-mail communication between parents of patients in pediatric primary care and pediatricians. In the content analyses of e-mail messages, topics well represented were medical information exchange, medical condition or update, medication information, and subspecialty evaluation. A number of personal and institutional features were associated with the likelihood of e-mail use between patients and providers. While benefits of e-mails in enhancing communication were recognized by both patients and providers, concerns about confidentiality and security were also expressed.

CONCLUSION

The e-mail is transforming the relationship between patients and providers. The rigorous exploration of pros and cons of electronic interaction in health care settings will help make e-mail communication a more powerful, mutually beneficial health care provision tool.

PRACTICE IMPLICATIONS

It is important to develop an electronic communication system for the clinical practice that can address a range of concerns. More efforts need to be made to educate patients and providers to appropriately and effectively use e-mail for communication.

Online communication between doctors and patients in Europe: status and perspectives

Background

Use of the Internet for health purposes is steadily increasing in Europe, while the eHealth market is still a niche. Online communication between doctor and patient is one aspect of eHealth with potentially great impact on the use of health systems, patient-doctor roles and relations and individuals’ health. Monitoring and understanding practices, trends, and expectations in this area is important, as it may bring invaluable knowledge to all stakeholders, in the Health 2.0 era.

Objective

Our two main goals were: (1) to investigate use of the Internet and changes in expectations about future use for particular aspects of communication with a known doctor (obtaining a prescription, scheduling an appointment, or asking a particular health question), and (2) to investigate how important the provision of email and Web services to communicate with the physician is when choosing a new doctor for a first time face-to-face appointment. The data come from the second survey of the eHealth Trends study, which addressed trends and perspectives of health-related Internet use in Europe. This study builds on previous work that established levels of generic use of the Internet for self-help activities, ordering medicine or other health products, interacting with a Web doctor/unknown health professional, and communicating with a family doctor or other known health professional.

Methods

A representative sample of citizens from seven European countries was surveyed (n = 7022) in April and May of 2007 through computer-assisted telephone interviews (CATI). Respondents were questioned about their use of the Internet to obtain a prescription, schedule an appointment, or ask a health professional about a particular health question. They were also asked what their expectations were regarding future use of the Internet for health-related matters. In a more pragmatic approach to the subject, they were asked about the perceived importance when choosing a new doctor of the possibility of using email and the Web to communicate with that physician. Logistic regression analysis was used to draw the profiles of users of related eHealth services in Europe among the population in general and in the subgroup of those who use the Internet for health-related matters. Changes from 2005 to 2007 were computed using data from the first eHealth Trends survey (October and November 2005, n = 7934).

Results

In 2007, an estimated 1.8% (95% confidence interval [CI], 1.5 - 2.1) of the population in these countries had used the Internet to request or renew a prescription; 3.2% (95% CI 2.8 - 3.6) had used the Internet to schedule an appointment; and 2.5% (95% CI 2.2 - 2.9) had used the Internet to ask a particular health question. This represents estimated increases of 0.9% (95% CI 0.5 - 1.3), 1.7% (95% CI 1.2 - 2.2), and 1.4% (95% CI 0.9 - 1.8). An estimated 18.0% (95% CI 17.1 - 18.9) of the populations of these countries expected that in the near future they would have consultations with health professionals online, and 25.4% (95% CI 24.4 - 26.3) expected that in the near future they would be able to schedule an appointment online. Among those using the Internet for health-related purposes, on average more than 4 in 10 people considered the provision of these eHealth services to be important when choosing a new doctor.

Conclusions

Use of the Internet to communicate with a known health professional is still rare in Europe. Legal context, health policy issues, and technical conditions prevailing in different countries might be playing a major role in the situation. Interest in associated eHealth services is high among citizens and likely to increase.

A review of the personal health records in selected countries and Iran

Personal Health Record (PHR) enables patients to access their health information and improves care quality by supporting self-care. The purpose of this study is to provide a comparative analysis of the concept of PHRs in selected countries and Iran in order to investigate the gaps between Iran and more advanced countries in terms of PHRs. The study was carried out in 2008-2009 using a descriptive-comparative method in Australia, the United States, England and Iran. Data was gathered from articles, books, journals and reputed websites in English and Persian published between 1995 and September 2009. After collecting the data, both advantages and disadvantages of each of concepts were analyzed. In the three countries considered in the present study the concepts of PHR, extracted from the literature, are that; a)patient/person be recognized as the owner of PHR; b)information be disclosed only to those authorized by the patient; c) and that PHR is created upon request and consent of the individual involved. Before PHRs can be profitably used in the health administration of a (developing) country, the necessary knowledge, infrastructures, and rules need to be developed.

EHR acceptance factors in ambulatory care: a survey of physician perceptions

With the U.S. government calling for electronic health records (EHRs) for all Americans by the year 2014, adoption of an interoperable EHR is imminent in America's future. However, recent estimates for EHR implementation in the ambulatory care environment are just over 10 percent. This second part of a two-part study examines EHR acceptance factors in an academic-based healthcare system. Innovation diffusion theory and the Technology Acceptance Model provide a combined theoretical framework for this case study. An online questionnaire was administered to 802 faculty, fellow, and resident physicians to explore the factors affecting attitudes toward EHR adoption. In this study, age, years in practice, clinical specialty, health system relationship, and prior computer experience were not predictors of EHR acceptance. In order to facilitate successful adoption of health information systems, social and behavioral factors must be addressed during the EHR planning phase.

Web usage data as a means of evaluating public health messaging and outreach

Background

The Internet is increasingly utilized by researchers, health care providers, and the public to seek medical information. The Internet also provides a powerful tool for public health messaging. Understanding the needs of the intended audience and how they use websites is critical for website developers to provide better services to the intended users.

Objective

The aim of the study was to examine the utilization of the chronic fatigue syndrome (CFS) website at the Centers for Disease Control and Prevention (CDC). We evaluated (1) CFS website utilization, (2) outcomes of a CDC CFS public awareness campaign, and (3) user behavior related to public awareness campaign materials and CFS continuing medical education courses.

Methods

To describe and evaluate Web utilization, we collected Web usage data over an 18-month period and extracted page views, visits, referring domains, and geographic locations. We used page views as the primary measure for the CFS awareness outreach effort. We utilized market basket analysis and Markov chain model techniques to describe user behavior related to utilization of campaign materials and continuing medical education courses.

Results

The CDC CFS website received 3,647,736 views from more than 50 countries over the 18-month period and was the 33rd most popular CDC website. States with formal CFS programs had higher visiting density, such as Washington, DC; Georgia; and New Jersey. Most visits (71%) were from Web search engines, with 16% from non-search-engine sites and 12% from visitors who had bookmarked the site. The public awareness campaign was associated with a sharp increase and subsequent quick drop in Web traffic. Following the campaign, user interest shifted from information targeting consumer basic knowledge to information for health care professionals. The market basket analysis showed that visitors preferred the 60-second radio clip public service announcement over the 30-second one. Markov chain model results revealed that most visitors took the online continuing education courses in sequential order and were less likely to drop out after they reached the Introduction pages of the courses.

Conclusions

The utilization of the CFS website reflects a high level of interest in the illness by visitors to the site. The high utilization shows the website to be an important online resource for people seeking basic information about CFS and for those looking for professional health care and research information. Public health programs should consider analytic methods to further public health by understanding the characteristics of those seeking information and by evaluating the outcomes of public health campaigns. The website was an effective means to provide health information about CFS and serves as an important public health tool for community outreach.

The effectiveness of a secure email reminder system for colorectal cancer screening

This study looks at the effectiveness of using a secure email system linked to an electronic health record to send reminders to patients in an effort to increase colorectal cancer (CRC) screening rates; 1397 subjects were randomized to receive usual care, a letter reminder or an email reminder which invited patients to pick up a fecal occult blood test at the lab for CRC screening. The number of completed CRC screenings was tallied after a 3 month study period. Rates of CRC screening in the 3 groups were 7.8% in the usual care group, 23.6% in the letter reminder group and 22.7% in the email group. Significant statistical difference was seen between usual care group and letter reminders (p<0.0005) and between usual care and email reminders (p<0.0005) but not between the letter reminders and the email reminders (p=7.11). Email reminders are as effective as letter reminders in increasing CRC screening rates.

A framework for predicting EHR adoption attitudes: a physician survey

With a focus on improving the quality of patient care, the President George W. Bush called for electronic health records (EHRs) for all Americans by the year 2014; however, recent estimates for EHR adoption in the ambulatory care environment are just over 10 percent. The objective of this study was to determine the individual characteristics and the social and technical factors that may contribute to physician acceptance of EHRs. This first paper of a two-part study presents a framework grounded in Diffusion of Innovations theory and the Technology Acceptance Model, which was developed using case study and survey methods, and tested using structural equation modeling (SEM). Model variables explained over 73 percent of the variance in attitude toward EHRs, and acceptable model fit was achieved. Lack of user acceptance continues to impede diffusion of EHRs, and this analysis supports the impact that leadership and other organizational changes have on user adoption.