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The American Journal of Managed Care December 2015
Interest in Mental Health Care Among Patients Making eVisits
Steven M. Albert, PhD; Yll Agimi, PhD; and G. Daniel Martich, MD
The Impact of Electronic Health Records and Teamwork on Diabetes Care Quality
Ilana Graetz, PhD; Jie Huang, PhD; Richard Brand, PhD; Stephen M. Shortell, PhD, MPH, MBA; Thomas G. Rundall, PhD; Jim Bellows, PhD; John Hsu, MD, MBA, MSCE; Marc Jaffe, MD; and Mary E. Reed, DrPH
Health IT-Assisted Population-Based Preventive Cancer Screening: A Cost Analysis
Douglas E. Levy, PhD; Vidit N. Munshi, MA; Jeffrey M. Ashburner, PhD, MPH; Adrian H. Zai, MD, PhD, MPH; Richard W. Grant, MD, MPH; and Steven J. Atlas, MD, MPH
A Health Systems Improvement Research Agenda for AJMC's Next Decade
Dennis P. Scanlon, PhD, Associate Editor, The American Journal of Managed Care
An Introduction to the Health IT Issue
Jeffrey S. McCullough, PhD, Assistant Professor, University of Minnesota School of Public Health; Guest Editor-in-Chief for the health IT issue of The American Journal of Managed Care
Preventing Patient Absenteeism: Validation of a Predictive Overbooking Model
Mark Reid, PhD; Samuel Cohen, MD; Hank Wang, MD, MSHS; Aung Kaung, MD; Anish Patel, MD; Vartan Tashjian, BS; Demetrius L. Williams, Jr, MPA; Bibiana Martinez, MPH; and Brennan M.R. Spiegel, MD, MSHS
EHR Adoption Among Ambulatory Care Teams
Philip Wesley Barker, MS; and Dawn Marie Heisey-Grove, MPH
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Susan Kirsh, MD, MPH; Evan Carey, MS; David C. Aron, MD, MS; Omar Cardenas, BS; Glenn Graham, MD, PhD; Rajiv Jain, MD; David H. Au, MD; Chin-Lin Tseng, DrPH; Heather Franklin, MPH; and P. Michael Ho, MD, PhD
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Patient-Initiated E-mails to Providers: Associations With Out-of-Pocket Visit Costs, and Impact on Care-Seeking and Health
Mary Reed, DrPH; Ilana Graetz, PhD; Nancy Gordon, ScD; and Vicki Fung, PhD
Health Information Technology Adoption in California Community Health Centers
Katherine K. Kim, PhD, MPH, MBA; Robert S. Rudin, PhD; and Machelle D. Wilson, PhD
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Dominique Comer, PharmD, MS; Joseph Couto, PharmD, MBA; Ruth Aguiar, BA; Pan Wu, PhD; and Daniel Elliott, MD, MSCE
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Michael F. Furukawa, PhD; Jennifer King, PhD; and Vaishali Patel, PhD, MPH

Patient-Initiated E-mails to Providers: Associations With Out-of-Pocket Visit Costs, and Impact on Care-Seeking and Health

Mary Reed, DrPH; Ilana Graetz, PhD; Nancy Gordon, ScD; and Vicki Fung, PhD
Patients with higher out-of-pocket visit costs, such as co-payments and deductibles, initiated provider contact by e-mail more often. Patients report that e-mailing changed their care-seeking behaviors and improved overall health.

Objectives: To understand when patients use secure e-mail messaging with healthcare providers across several types of questions or concerns, associations between out-of-pocket costs for in-person visits and use of secure messaging, and to examine patient-reported impacts on care-seeking behavior and overall health.

Study Design: Cross-sectional survey of patients in an integrated healthcare delivery system, with access to a patient portal to send secure e-mail messages to providers at no out-of-pocket cost.

Methods: The study included patients with a chronic condition (N = 1041). We described patient-reported preferences for contacting providers and patient-reported impact of e-mail use on phone calls, in-person visits, and overall health. We used multivariate analyses to examine patient characteristics associated with using e-mail as a first contact method, and effects on care-seeking and health.

Results: Overall, 56% of patients sent their provider an e-mail within 1 year, and 46% reported e-mail as their first method of contact for 1 or more types of medical concerns. After adjustment, higher out-of-pocket costs for in-person visits were significantly associated with choosing e-mail as a first method of contact (P <.05). Among patients who had e-mailed their provider, 42% reported that it reduced their phone contacts, 36% reduced in-person office visits and 32% reported e-mailing improved their overall health.

Conclusions: Patients reported using e-mail broadly to initiate conversations with their providers, and patients with higher out-of-pocket costs for in-person visits were more likely to choose e-mail as a first contact method. Use of secure e-mails reduced patients’ use of other types of healthcare and resulted in improved overall health.

Am J Manag Care. 2015;21(12):e632-e639
Take-Away Points
In a survey of patients with a chronic condition and with access to send secure e-mail messages to providers, nearly half had used e-mail as their first method of contacting providers for various types of health concerns. 
  • Patients with higher out-of-pocket cost-sharing for visits were significantly more likely to report e-mail as their first method of contact with a health concern. 
  • More than 1 in 3 patients who sent an e-mail to providers reported that it reduced their phone contacts or office visits. 
  • Nearly one-third of patients who sent an e-mail to providers reported that it had improved their overall health.
Secure electronic messages offer patients and physicians an additional channel for communication and may serve as a unique mechanism for healthcare delivery. Although recent estimates show that most physicians in the United States are not yet regularly communicating with their patients electronically, most patients indicate an interest in communicating directly with their healthcare providers online.1,2-5 In order to receive the second stage of federal incentive payments for “meaningful use” of electronic health records and to avoid eventual financial penalties, clinicians will need to offer patients access to their health information through Web-based tools and to exchange secure electronic messages.6 However, the effects of these policy-driven shifts toward more electronic information and communication on patient care-seeking decisions and healthcare utilization are unclear.

There is limited information on what types of health concerns patients discuss with their providers using secure messaging, subsequently conflicting with evidence on the ways in which having Web-portal access affects in-person care-seeking behavior. Additionally, there is little attention paid to how patients’ cost-sharing for in-person visits affects their choice to contact their providers by e-mail.7-14 To understand how patients report their use of secure messaging tools to discuss concerns or questions about their health with their healthcare providers, we surveyed patients in a large health system that offers patient–provider secure electronic messaging tools, focusing specifically on patients with a chronic condition. We examined patient preferences for contacting healthcare providers across a variety of types of questions and concerns, whether cost-sharing for in-person visits was associated with this decision, and the patient-reported impact of secure message use on their in-person visits and overall health. We hypothesized that preferences for first contact method would vary by type of health concern, and that they would be affected by out-of-pocket costs.


Kaiser Permanente Northern California is an integrated delivery system with more than 3 million members. Health system members who register to use the password-protected patient portal website are able to exchange secure electronic messages directly with a provider in their healthcare team. Patients and providers are each notified when they have received a new message. There is no charge to the patient for using the patient portal, which also offers patients the ability to view lab results, request medication refills, and to view portions of their health records and visit summaries. Patients in this health system can also schedule nonemergency office visits through the portal website or by telephone.

The Kaiser Foundation Research Institute Institutional Review Board reviewed and approved the study protocol, waiving the requirement for informed consent.

Study Population 

Our source population for this study included all adult patients (18 years or older) who were in at least 1 of the health plan’s clinical chronic disease registries for asthma, coronary artery disease, congestive heart failure, diabetes, or hypertension during 2010. We studied patients with chronic conditions in order to focus on patients with at least 1 condition to discuss with a provider, but our survey asked generally about patient–provider messages for any type of condition or concern. Because the survey included questions about the impact of patient out-of-pocket costs (eg, co-payments and deductibles) on care-seeking behavior, we limited our sample to patients who were continuously enrolled through an employer-sponsored health insurance plan with no cost-sharing changes in their health plan benefits during 2010.

To ensure a sufficient number of participants who had recently sent a secure message and who had higher out-of-pocket costs for in-person care, we used a stratified random survey sample. Using automated records from the 12-month period before our study began, we randomly selected 25% of our sample from those who had not sent any secure messages and 75% from those that had sent at least 1 secure message. We also stratified the sample to include 25% from patients with a high-deductible health plan and 75% from patients without a high-deductible health plan. The high-deductible plans in our study met the IRS requirements for health savings account eligibility, including a deductible of $1200 or higher for an individual ($2400 for family coverage) that applied to most healthcare services, including nonpreventive office visits.15

Beginning in June 2011, we mailed each potential participant a study introduction letter, a reply postcard, and a questionnaire with a postage-paid return envelope. We offered the option of completing the survey questionnaire by mail, by Web-based electronic survey, or by telephone interview in order to include of as many respondents as possible regardless of technology access or preferences, and in order to maximize response rates. Between June and December of 2011, trained interviewers contacted those who had not responded to our initial mailing in order to conduct telephone interviews, attempting to reach potential participants during different times of the day on weekdays and weekends. As needed, interviewers also called respondents who had mailed the written survey to complete and clarify any missing items. At the end of our data collection period, we again mailed a copy of the survey with a prepaid return envelope to all potential participants we had not been able to reach. All study participants received a $5 coffee gift card.

Of the total 1314 potential respondents contacted: 117 could not be reached after 15 phone call attempts, 183 were ineligible for study participation (a language barrier or health problem prevented them from completing an English-language interview or survey or they could not be reached due to incorrect contact information), and 1041 patients completed the study questionnaire (the response rate among eligible participants was 79%). Among all respondents, 51% completed the survey by telephone, 34% returned the survey by mail, and 15% completed the Internet-based survey. Comparing respondents with nonrespondents, women and respondents older than 65 years were more likely to complete the survey (P <.05).


The survey questionnaire asked respondents how often they use the Internet for any reason and what devices they use to access the Internet. We also asked participants to report if, in the previous 12 months, they had any of 5 types of health concerns: 1) questions about a medical test result, 2) questions about a new health condition, 3) questions about an ongoing or chronic health condition, 4) questions about a medication, or 5) a request for a referral.  For each type of concern reported, we then asked respondents how they first contacted their provider or the healthcare system (ie, telephone call for advice or to schedule a visit, e-mailing their provider, visiting the emergency department, or no contact at all). We grouped phone calls for advice and to schedule a visit together since the patients’ first method of contacting the health system was by phone.

If e-mail was the preferred method of provider contact for a given type of concern, we then asked respondents what other method they would have used to contact their provider if the option to send a secure e-mail message had not been available. Respondents who reported past use of secure messaging also answered questions about which provider they had e-mailed and how long it took to receive a response from the provider. We also asked whether using secure messaging affected the number of times they contacted their provider by phone or the number of in-person office visits, and if using the secure messaging tool to e-mail their provider had an impact on their overall health status.

We asked all respondents to report their health plan’s cost-sharing requirements for doctor’s office visits and several demographic characteristics, including education, annual household income, race/ethnicity, marital status, and self-reported health status. Using health plan administrative data, we identified participants’ age, gender and DxCG comorbidity score (diagnosis-based risk score).16,17


Because our study used a stratified sample, all analyses and results presented were weighted using study sampling proportions to represent the overall source population of patients with chronic conditions. We describe participants’ access to the Internet, with participants who reported never or rarely using the Internet categorized as not accessing the Internet. We also calculated the percentages of respondents who reported the 5 specific types of concerns in the last 12 months, their preferred method of contact for each type of concern, and the percentage who had registered to use the patient portal website. Among those who were Internet users and had registered to use the portal, we calculated the percentage who reported using secure messaging with any healthcare provider in the last 12 months, the type of provider e-mailed, and the average time to provider response. Among those who e-mailed their provider, we calculated the percentages who reported that e-mails with their provider changed the number of calls or visits with providers, or had an impact on their overall health.

Among patients who reported having any of the 5 specific types of health concerns, we used multivariable logistic regression to examine the association between reporting a preference for using e-mail to contact providers for any type of concern and visit cost-sharing levels, adjusting for patient characteristics, including gender, race-ethnicity, age, marital status, education, self-reported health, income, and comorbidity score. All multivariate analyses account for the survey sampling strategy in the point estimates and variance estimation (Stata version 9.0 [StataCorp LP, College Station, Texas] using the svlogit command). We also used multivariable logistic regression to examine the association between reporting a preference for using e-mail as the first method to contact providers and reported impacts on phone contact and office visit rates, with adjustment for patient characteristics. We categorized respondents as having high visit cost-sharing if they reported having a deductible that applied to office visits or out-of-pocket cost (eg, co-payments or deductibles) of $60 or higher. We then computed the adjusted percentage of respondents who reported using e-mail as a first method of contact by fitting results from the logistic regression model by each patient characteristic and reported cost-sharing levels for office visits.

Table 1 shows the characteristics of the 1041 participants in our study after weighting. Among the 71% of participants who access the Internet at least monthly, 79% reported sending at least 1 secure message to their provider in the past year (24% sent 1-2, 29% sent 3-5, and 26% sent >5 e-mails). Figure 1 shows the types of providers they e-mailed and the reported provider response times.

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