Crossing the Digital Divide: Evaluating Online Communication Between Patients and Their Providers

Published Online: September 01, 2004
Steven J. Katz, MD, MPH; Neil Nissan, BA; and Cheryl A. Moyer, MPH

Objective: To address provider, payer, and patient concerns about the use of online communication in healthcare settings by performing a randomized controlled trial of a Web-based patient-provider communication tool in primary care.

Subjects and Methods: Forty-one staff physicians and 91 residents in 4 primary care centers were randomized to a Web-based online communication system. Patients of intervention physicians were encouraged to communicate via the system about health issues, scheduling, prescription renewals, referrals, and billing. Data collected included patient Web use, e-mail use, telephone calls, visit distribution, and physician and patient attitudes toward and satisfaction with communication.

Results: One thousand thirty-eight patients sent 2238 messages during the 40-week study. Half of the messages were directly related to a patient's health; half were administrative. Patient Web use peaked at 8.5 weekly messages per 100 scheduled visits. Patient email and telephone volume remained similar across groups. Intervention physicians reported more positive attitudes toward Web-based communication than control physicians (mean Web benefits scale score, 4.0 vs 1.1; P = .008), but there were no between-group differences in attitudes toward communication in general. Patients and physicians reported differential preferences for the use of online communication based on problem complexity and sensitivity.

Conclusions: Web-based messaging was lower than expected because of patient-related factors and limitations of the technology. Patients, physicians, and staff had positive attitudes toward online communication. There was no detectable difference in communication volume between study groups, but more sensitive measures of work burden need to be developed and evaluated.

(Am J Manag Care. 2004;10:593-598)

Advances in technology have motivated interest in the role of online patient-provider communication in clinical settings. Communicating online could reduce barriers associated with traditional modes of communication,1-4 yet it has diffused slowly in clinical practice.5 Lack of reimbursement for online communication has motivated questions about whether it will reduce use of other clinic resources or will create additional work for staff.6 Providers have voiced concerns about appropriate uses of online communication in clinical practice.7-9 Patients have been reluctant to communicate online because of lack of experience and uncertainty about provider responses.10 In this issue of the Journal, Houston et al11 report as a barrier to use of online communication that adults who used the Web for health information frequently voiced concerns about bothering physicians. Finally, there is uncertainty about how to build and integrate Web-based communication tools into existing operations and information systems.12-14

We built a Web-based patient-provider communication system and performed a randomized controlled trial of its use in an academic primary care setting. The study addressed several questions: Does Web communication between patients and the clinic team substitute for personal e-mail or telephone calls? Does Web-based communication affect patient or provider perceptions of communication? We hypothesized that a Web-based communication tool would reduce e-mail and telephone calls and improve communication between patients and their providers.


A randomized controlled trial was performed in 4 university-affiliated primary care clinics for a 40-week period from September 2001 through June 2002. Three faculty physicians and 2 residents declined to participate. Forty-one faculty physicians (averaging 37 scheduled visits per week) and 91 resident physicians (averaging 6 scheduled visits per week) in general medicine and family practice were randomized into 2 groups, intervention (n = 65) and control (n = 67). The patients of intervention physicians were encouraged to use a secure Web-based tool to communicate with their clinic staff about health and administrative issues and prescription renewals. The Web site had educational content addressing appropriate message content, expected response times, and message handling by clinic staff. Incoming messages were routed to appropriate clinic staff, who entered the site through a secure log-in. Patients were prompted through regular e-mail to enter the Web site to read responses from the staff. Physicians did not have access to the Web system, and staff contacted physicians for pertinent messages through the usual means. Patients of intervention physicians were encouraged to use the Web system through promotion, including cards distributed by intervention physicians and brochures mailed to patient homes.

Data Collection

Information about the number and types of Web messages was collected from the Web site. E-mail volume was measured based on physician recall of the number of e-mail messages received directly from patients during the previous week. On average, 91.7% of staff physicians responded vs 67.4% of residents. Missing estimates for residents were imputed to zero because feedback suggested that these residents had low e-mail use with patients. Staff logs were used to collect data on telephone call volume by type of call and physician.

Self-administered patient and physician surveys conducted at the end of the study assessed attitudes toward Web and e-mail communication, preferences for different modes of communication, and satisfaction with communication.9,10 Because there was no valid physician-patient roster, we selected patients in 2 equally divided groups: 425 patients who had seen an intervention physician 1 or more times and a control physician no more than 1 time during the study period, and 425 patients who had seen a control physician 1 or more times and an intervention physician no more than 1 time during the study period. The Dillman method was used to maximize response rates.15

Variables and Analysis

Three use variables were constructed at the physician level. These included (1) weekly patient Web messages per 100 scheduled visits (number of patient Web messages per week divided by the mean number of scheduled visits per week during the study period × 100), (2) weekly patient e-mails per 100 scheduled visits (number of physician-reported patient e-mails per week divided by the mean number of scheduled visits per week during the study period × 100), and (3) weekly telephone calls per 100 scheduled visits.

Physician survey variables included a "Web benefits" scale that indicated attitudes toward using the Web with patients, with higher scores indicating more favorable attitudes (4 items, α = .88), and a general communication scale indicating attitudes toward communication with patients and staff (4 items, α = .82). Finally, we examined preferences for different modes of communication for different clinical issues.

Variables from the patient survey included the following: (1) A Web benefits scale that indicated attitudes toward using Web communication with healthcare providers, with higher scores indicating more favorable attitudes (3 items, α = .90). (2) Preferences for different modes of communication using questions similar to those on the physician survey. (3) A general communication scale indicating attitudes toward communication with and access to physicians and staff outside of visits, with higher scores indicating more favorable attitudes (4 items, α = .85).

Poisson regression analysis was used to examine differences in trends in counts of the different use measures across the 5 periods between the physician study groups, with physician as the unit of analysis. For example, in one model, telephone volume was the dependent variable, and independent variables included group (intervention vs control), periods (1 through 5), group and period dummy variables, physician status (resident vs faculty physician), and dummy variables indicating study clinic site. Differences in physician and patient attitude scale scores were examined using ordinary least squares regression analysis. The dependent variables were the various scales specified as intervals. Independent variables for the physician scale models included study group, physician type (resident vs faculty physician), and clinic. Independent variables for the patient scales models included study group, age, sex, and clinic. The study was approved by the University of Michigan Institutional Review Board.


Baseline Characteristics of the Physician Sample

Intervention and control physician groups did not differ with regard to the distribution of faculty physicians (27.4% in the intervention group vs 32.3% in the control group, P = .27), female sex (40.1% vs 41.2%, P = .59), or mean number of scheduled visits per week.

Resource Use

One thousand thirty-eight patients registered on the Web site and sent 2238 messages (41.8% of patients sent no messages, 19.4% sent one, 16.3% sent 2-3, and 22.5% sent ≥ 4 messages). The growth of patient registration and messaging was uniform during the study period. About half of the messages were related to health-related follow-up, inquiries, or requests for test results. Approximately 20% were appointment related, 15% were referral requests, and 12% were prescription requests or renewals.

Table 1 gives Web, e-mail, and telephone volume for 5 one-week data collection periods during the study among the intervention and control group physicians. The trend in Web message use (the mean number of weekly Web messages per 100 scheduled visits) was modest, approaching that of e-mail use for the intervention physician group. E-mail and telephone volume trends (the mean number of weekly messages reported in the prior week per 100 scheduled visits) were similar between study groups (Wald test, 8.1; P = .09 for e-mail; and Wald test, 9.1; P = .18 for telephone; controlling for physician type and clinic).


Physician Survey

The response rate to the survey was 71.2% (37 faculty physicians and 57 residents). Table 2 gives perceived benefits of Web communication with patients. Intervention physicians perceived greater benefits of Web communication than control physicians across all items. For example, intervention physicians were more likely than control physicians to believe that Web communication would be "a good way for patients to contact me" (56.3% vs 41.3%, P = .04). The mean score for the Web benefits scale was 4.0 in the intervention group vs 1.1 in the control group (P = .008, controlling for physician type and clinic).


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