Experiences of Patients Who Were Early Adopters of Electronic Communication With Their Physician: Satisfaction, Benefits, and Concerns

Published Online: September 01, 2004
Thomas K. Houston, MD, MPH; Daniel Z. Sands, MD, MPH; Mollie W. Jenckes, MHS; and Daniel E. Ford, MD, MPH

Objective: To explore the experiences of patients who were early adopters of e-mail communication with their physicians.

Methods: Patients' experiences were assessed with an Internetbased survey of 1881 individuals and in-depth telephone follow-up interviews with 56 individuals who used e-mail to communicate with providers. Two investigators qualitatively coded interview comments independently, with differences adjudicated by group consensus.

Results: A total of 311 (16.5%) of the 1881 individuals reported using electronic mail to communicate with their physicians. Compared with the population-based Behavioral Risk Factor Surveillance Survey, users of e-mail with physicians were twice as likely to have a college education, were younger, were less frequently ethnic minorities, and more frequently reported fair/poor health. Among the 311 patients who used e-mail with their physicians, the most frequent topics were results of laboratory testing and prescription renewals. However, many of the 311 users (21%) also reported using asynchronous e-mail inappropriately to convey urgent or sensitive issues (suicidality, chest pain, etc). Almost all (95%) perceived that e-mail was more efficient than the telephone. Important benefits uncovered from the interviews were that some patients felt more emboldened to ask questions in e-mail compared with face-to-face communication with doctors, and liked the ability to save the e-mail messages. Users also expressed concerns about privacy.

Conclusion: Patients that use electronic communication with their physicians find the communication efficient for disease management. Further patient education about inappropriate use of email for urgent issues is needed.

(Am J Manag Care. 2004;10:601-608)

Use of the Internet by patients is increasing.1-6 In addition to seeking health information, individuals also can use the Internet to communicate with each other in online support groups,7-9 and can potentially use the Internet to communicate with their healthcare providers.1,10,11 In a survey of primary care patients who had Internet access, more than 80% wanted to use e-mail to communicate with their physician.12 However, only 6% of patients have used e-mail to communicate with their healthcare provider.6

Effective physician-patient communication is important to patient satisfaction, treatment adherence, and health outcomes.13-16 The recent report of the Institute of Medicine, Crossing the Quality Chasm, states that "patients should receive care whenever they need it and in many forms, not just face-to-face visits...access to care should be provided over the Internet, by telephone, and by other means."17 Electronic patient-centered communication, using e-mail or Web-based technology, has the potential to enhance physician-patient interactions by providing asynchronous, self-documenting communication of patient questions and physician advice.10 However, the utilization of physician-patient electronic communication is low, and physicians report concerns including excessive demands on their time and medicolegal risks.11,18-22

Patient perceptions of the relative utility of electronic communication also may be important for incorporating this technology into clinical practice. To better understand patient factors that may influence the possible future of patient-physician electronic communication, we chose to explore the experiences of the early adopters of electronic communication, patients who already communicate with their physicians by electronic mail. Our research questions included the following:

  • What are the characteristics of these early adopters of patient-physician e-mail?
  • What topics do these patients address in e-mail to their providers?
  • What do these patients perceive to be the benefits of and problems with e-mail communications?

To conduct this hypothesis-generating research, we used a combination of quantitative surveys and qualitative in-depth interviews with patients who currently communicate with their providers through the Internet.


Study Design and Subjects

We conducted a cross-sectional study with data collected from 2 sources: (1) an Internet-based survey of patients who use the Internet to look for health information and (2) follow-up in-depth telephone interviews with patients. We targeted early adopters to search for what is currently working and not working with electronic patient-centered communication. The data collection for this study was part of a larger research project funded by the Bayer Institute for Healthcare Communication to explore the potential of patient-physician e-mail communication from the perspective of physicians and patients.1

Recruitment Procedures

Use of electronic mail to communicate with physicians is still uncommon in the general population; therefore, recruiting patients for this study was a challenge. Because early adopters of e-mail with their physicians also would be likely to use the Internet to search for health information, we chose to recruit and survey patients who were using the Internet for this purpose.

A patient survey was developed and implemented online. After receiving approval from the Johns Hopkins Committee on Clinical Investigation, InteliHealth.com, a health media company owned by Aetna US Healthcare and affiliated with Harvard Medical School, agreed to post a volunteer recruitment request. InteliHealth has a popular consumer health information Web site available to any consumer searching for health information online. By collaborating with InteliHealth, we hoped to have the widest possible visibility of our request for volunteers among our target population. A link to the survey also was posted on the consumer Web site of CareGroup Healthcare System, a Harvard-affiliated integrated health delivery network in the Boston area. The survey was available from May through October 2001. We confirmed that each response was from a unique IP address, thus lessening the chance that we had repeat users. After recruiting approximately 300 individuals who reported that they had used electronic mail to communicate with their physicians, we closed enrollment.

After the questionnaire portion of the study was completed, we asked participants who had used e-mail with their physicians whether they would agree to participate in an in-depth telephone interview. Those who agreed entered their e-mail address onto the secure server. Initially, 6 patients were contacted by a research assistant through e-mail to schedule an in-depth telephone interview. These interviews were audiotaped and reviewed to identify themes. Based on the results of initial interviews, additional open-ended questions were added to the telephone interview. Additional audiotaped interviews were completed until preliminary review of tapes suggested that themes had been saturated. All interviews were transcribed verbatim.

Survey and Interview Content

The Internet-based survey included demographic questions (age, sex, ethnicity, level of education); health-related questions (general health status, number of medications, and number of visits to healthcare provider); and a screening question: "In a typical month, please estimate the average number of e-mails you send to your physician(s) and your physician's staff." To be inclusive, this screening question considered any e-mail to the physician practice. In our interviews, we asked those who responded to the Internet survey whether e-mail communication was with the physician or the physician's staff. Those who reported more than "none" were considered users of e-mail with their physician. Individuals who had used electronic mail with their physician were asked additional questions related to the physician's specialty; the clinical topics discussed through e-mail; the perceived benefits of e-mail and problems; and their overall satisfaction with e-mail communication with their physician. Clinical topics, benefits, and problems were picked from a list that was derived through an iterative process with input from all the authors (2 of whom have considerable clinical experience with patient e-mail) and then in pilot-testing with students at the Johns Hopkins School of Public Health.

We triangulated from the quantitative surveys using the in-depth telephone interviews. Interviewers asked a series of open-ended questions to guide the interviews, including: "How has e-mail with your physician helped you and your doctor manage your health conditions?" "Tell me about the most recent e-mail exchange you have had with your physician" "How is e-mail different than telephone contact?" We taught interviewers to probe for specific examples. Interviews averaged 15 to 20 minutes.


We used Mantel-Haenszel χ2 trend statistics to compare demographic characteristics and health status variables of individuals participating in our Internet- based survey who had used electronic mail with their physicians with the characteristics and health status variables of those who reported not using e-mail with their healthcare providers. To further characterize this select sample of patients who used electronic mail with their physicians, we compared their demographic characteristics with those of participants in the 2000 Behavioral Risk Factor Surveillance Survey (BRFSS). The Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System is an ongoing, cross-sectional, state-based telephone survey conducted among a representative sample of each state's adult population. The purpose of this surveillance system is to collect uniform, population-based data on preventive health practices and risk behaviors that are linked to chronic diseases and injuries in the US population. Most states use either a disproportionate stratified sample or a Mitofsky-Waksberg–type sample design to draw a random sample from the set of all possible telephone numbers based on area codes and prefixes (www.cdc.gov/brfss/pdf/userguide.pdf). Thus, comparison data from the 2000 BRFSS survey were adjusted for the complex survey design.

Using descriptive statistics, we summarized the content of the patients' e-mails, perceived benefits, and potential concerns related to patient-physician e-mail. We measured the strength of the association between the level of satisfaction with electronic mail and the perceived impact on patients' medical care, concerns, and demographic characteristics using χ2 tests and multivariable logistic regression.

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