Currently Viewing:
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
Impact of a National Specialty E-Consultation Implementation Project on Access
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
E-Consult Implementation: Lessons Learned Using Consolidated Framework for Implementation Research
Leah M. Haverhals, MA; George Sayre, PsyD; Christian D. Helfrich, PhD, MPH; Catherine Battaglia, PhD, RN; David Aron, MD, MS; Lauren D. Stevenson, PhD; Susan Kirsh, MD, MPH; P. Michael Ho, MD, MPH; and Julie Lowery, PhD
Currently Reading
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
Characteristics of Residential Care Communities That Use Electronic Health Records
Eunice Park-Lee, PhD; Vincent Rome, MPH; and Christine Caffrey, PhD
Using Aggregated Pharmacy Claims to Identify Primary Nonadherence
Dominique Comer, PharmD, MS; Joseph Couto, PharmD, MBA; Ruth Aguiar, BA; Pan Wu, PhD; and Daniel Elliott, MD, MSCE
Physician Attitudes on Ease of Use of EHR Functionalities Related to Meaningful Use
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.
Among patients who reported having each type of health concern, Figure 2 shows the reported first contact method. After multivariate adjustment, patients who were female, who used the Internet more often, or who reported higher out-of-pocket cost for in-person visits (≥$60) were statistically significantly more likely to choose to e-mail their provider as a first method of contact (P <.05) (Table 2). After adjusting for patient characteristics, 85% of patients with higher cost-sharing for in-person visits reported choosing e-mail as their first contact method compared with 63% of patents with lower cost-sharing.

Across the types of health concerns, 85% to 91% of those who reported e-mail as their first method of provider contact indicated that if e-mail was not available, they would instead have contacted their provider by phone for advice or to schedule a visit; 4% to 11% reported that they would have scheduled a visit through the health plan website. Less than 3% reported that they would have avoided contact with their provider altogether if e-mail had not been available, and less than 1% reported that they would have instead sought care at the emergency department.

Among all participants who exchanged a secure message with their provider, Figure 3 shows the reported impact on office visits and phone calls with the health system. Overall, 42% reported that the number of times they contacted the health system by phone decreased because of e-mail exchanges with their provider, 36% reported that their number of office visits decreased because of e-mail exchanges with their provider, and 32% reported that being able to communicate via e-mail improved their overall health. In multivariate analyses adjusting for patient characteristics, participants who reported e-mail as their first method of contact for any type of concern were significantly more likely to report that using e-mail had decreased their number of phone contacts with health system by phone and the number of office visits they had (P <.001). After adjustment, 50% of those who reported using e-mail as their first method of contact reported that it decreased the number of calls, 42% reported that it decreased the number of office visits, and 35% that it improved their overall health compared with 14%, 11%, and 22%, respectively, of those who did not have any preference for e-mail as a first method of contact.

In a survey of patients with a chronic condition within a healthcare setting that offers patients the ability to send secure electronic messages to their healthcare provider, we found that a large proportion of patients used e-mail as their first method of contacting providers across multiple types of health-related concerns. Patients with higher out-of-pocket cost-sharing for in-person visits were statistically significantly more likely to report e-mail as their first method of contact with a health question. While the majority of patients who e-mailed their provider reported that this did not affect their number of phone contacts or office visits, more than 1 in 3 reported that their phone contacts or office visits decreased because of e-mail exchanges with providers, and nearly one-third reported that exchanging e-mails with their provider had improved their overall health.

Secure patient portals have been proposed by the Institute of Medicine as a promising method of decreasing medical errors and increasing healthcare quality.18 Although the majority of US adults value Web-based access to their medical records as important, in 2013, only 28% of Americans were offered access to their online medical record.1  However, Stage 2 of the Meaningful Use federal programs that offer payment through the Medicare and Medicaid programs for demonstrating “meaningful use” of electronic health records will require clinicians to access and exchange secure e-mails with patients. Still, although our study was conducted in an integrated delivery system, many other reimbursement arrangements may limit the use of patient–physician e-mail, and Medicare does not generally provide separate payment for secure message exchanges.19,20

It is unclear how these broad changes in electronic data and communication access will change patient care-seeking behavior and outcomes. Our study finding of high rates of use of electronic messaging as the first method of contact for a range of health-related questions will likely become increasingly widespread as more patients and clinicians gain access to, and begin using, these tools regularly. Because patients in our study largely reported that they would call the health system for advice or to schedule a visit if e-mail had not been available, this initial contact shift likely has consequences for telephone communication and in-person utilization patterns as well. We found that one-third of those who e-mailed their provider reported that this communication decreased their use of in-person visits.

With the rapid growth of healthcare costs, health plan benefits that include high levels of patient cost-sharing (such as high deductibles), in order to curb demand for services, have been growing in popularity with policy makers and employers. High-deductible health plan enrollment will likely increase further with implementation of health reform in the Affordable Care Act.21 Several studies have demonstrated that cost-sharing, in various forms (eg, co-payments, deductibles), reduces utilization of medical services,22-26  but may lead to decreases in necessary care, including for chronic conditions.27-32 In addition to the cost-sharing associated with a doctor’s office visit, patients often face additional barriers and costs to seeking in-person care, such as difficulty getting time off from work or arranging transportation or childcare. The convenience of e-mail may reduce these barriers to accessing care. Also, our finding of higher rates of patients using secure messaging as their first method of contact when facing higher out-of-pocket costs for in-person care may signal changes in patients’ care-seeking patterns that could become increasingly common as patient cost-sharing levels continue to grow and the ability to communicate with providers electronically becomes more widespread.

Existing evidence on the impact of patient use of patient portal websites on healthcare use and health outcomes has been limited and the results are conflicting.7,12,33,34 Previous studies do not capture the patient-reported choice to use electronic tools relative to more traditional in-person types of healthcare services; it is challenging to identify switches between types of services or delays in healthcare service use using administrative data sources. We uniquely captured patients’ own reports of initial methods for contacting their healthcare providers according to type of health concern and patient-reported impacts of e-mail on visits and health. Some patients explained that issues such as lab orders, medication changes, and patient questions could be addressed by e-mail and could reduce the need for an in-person visit. In addition, patients noted that greater information availability and engagement in their own care improved the management of their conditions and overall health. Overall, we found that patients regularly used secure messages to initiate conversations with their providers across a wide range of types of health questions and concerns and many report that these exchanges improved their health.


The direct generalizability of our findings is limited to the populations and delivery system setting of our study; however, since we studied patients’ self-initiated e-mail exchanges with their providers, our findings may reflect more general patient care-seeking behavior. Also, while our study is based on patient-reported survey data, automated clinical data sources are unlikely to capture patients’ initial health concerns and care-seeking decisions that we present. These patient-reported findings do complement previous studies, in the same integrated delivery system, in which providers report that electronic tools and messaging facilitated care coordination, by improving communication and providing informational continuity.35,36 Additionally, although our study focused only on out-of-pocket charges for healthcare services such as co-payments and deductibles, patients may have also had other unmeasured personal expenses for transportation, lost wages, childcare, etc, associated with any healthcare encounter. Overall, the study data are cross-sectional; thus, these findings are not designed to establish causality. Future studies should continue to examine the impact of patient–provider e-mail use on healthcare-seeking behavior, clinical care delivery work flow, and patient outcomes.

We found that patients with chronic conditions sent secure e-mail messages to their providers as a first method of contacting the healthcare delivery system for a wide variety of health concerns, and that higher out-of-pocket costs for in-person visits were associated with use of e-mail. Nearly one-third of respondents who used this tool reported that e-mailing their healthcare providers had improved their overall health, and more than 1 in 3 reported that e-mailing their provider decreased their phone calls to their providers or their in-person doctor’s office visits. As more patients gain access to patient portal tools associated with an electronic health record, patient-provider e-mails may shift the way that healthcare is delivered and have the potential to impact efficiency, quality, and health outcomes.

Author Affiliations: Kaiser Permanente Division of Research (MR, IG, NG), Oakland CA; University of Tennessee Health Science Center (IG), Memphis TN; Mongan Institute for Health Policy, Massachusetts General Hospital (VF), Boston MA.

Source of Funding: Kaiser Permanente Community Benefit Fund.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MR, NG, IG, VF); acquisition of data (MR, IG); analysis and interpretation of data (MR, NG, IG, VF); drafting of the manuscript (MR, NG, IG); critical revision of the manuscript for important intellectual content (MR, IG, VF); statistical analysis (MR, IG, VF); provision of patients or study materials (MR, IG); obtaining funding (MR, IG); administrative, technical, or logistic support (MR, IG). 

Address correspondence to: Mary Reed, DrPH, Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612. E-mail:

1. Patel V, Barker W, Siminerio E. Individuals’ access and use of their online medical record nationwide. Office of National Coordinator for Health Information Technology website. Published September 2014. Accessed December 3, 2015.

2. Moyer CA, Stern DT, Dobias KS, Cox DT, Katz SJ. Bridging the electronic divide: patient and provider perspectives on e-mail communication in primary care. Am J Manag Care. 2002;8(5):427-433.

3. Stone JH. Communication between physicians and patients in the era of e-medicine. N Engl J Med. 2007;356(24):2451-2454.

4. Byrne JM, Elliott S, Firek A. Initial experience with patient-clinician secure messaging at a VA medical center. J Am Med Inform Assoc. 2009;16(2):267-270.

5. Sustainable health communities: a manifesto for improvement. Optum Institute website. Published 2011. Accessed December 3, 2015.

6. Fronstin P. Findings from the 2011 EBRI/MGA Consumer Engagement in Health Care Survey. EBRI Issue Brief. 2011(365):1-26.

7. Zhou YY, Garrido T, Chin HL, Wiesenthal AM, Liang LL. Patient access to an electronic health record with secure messaging: impact on primary care utilization. Am J Manag Care. 2007;13(7):418-424.

8. Liederman EM, Lee JC, Baquero VH, Seites PG. Patient-physician Web messaging: the impact on message volume and satisfaction. J Gen Intern Med. 2005;20(1):52-57.

9. Bergmo TS, Kummervold PE, Gammon D, Dahl LB. Electronic patient-provider communication: will it offset office visits and telephone consultations in primary care? Int J Med Inform. 2005;74(9):705-710.

10. Baer D. Patient-physician e-mail communication: the Kaiser Permanente experience. J Oncol Pract. 2011;7(4):230-233.

11. Ross SE, Moore LA, Earnest MA, Wittevrongel L, Lin CT. Providing a Web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial. J Med Internet Res. 2004;6(2):e12.

12. Palen TE, Ross C, Powers JD, Xu S. Association of online patient access to clinicians and medical records with use of clinical services. JAMA. 2012;308(19):2012-2019.

13. Zhou YY, Kanter MH, Wang JJ, Garrido T. Improved quality at Kaiser Permanente through e-mail between physicians and patients. Health Aff (Millwood). 2010;29(7):1370-1375.

14. Harris LT, Haneuse SJ, Martin DP, Ralston JD. Diabetes quality of care and outpatient utilization associated with electronic patient-provider messaging: a cross-sectional analysis. Diabetes Care. 2009;32(7):1182-1187.

15. Health savings accounts—2011 indexed amounts. United States Department of Treasury website. Updated August 3, 2011. Accessed October, 2013.

16. Ash AS, Ellis RP, Pope GC, et al. Using diagnoses to describe populations and predict costs. Health Care Financ Rev. 2000;21(3):7-28.

17. Ellis RP, Pope GC, Iezzoni L, et al. Diagnosis-based risk adjustment for Medicare capitation payments. Health Care Financ Rev. 1996;17(3):101-128.

18. Health information technology and patient safety: building safer systems for better care [media advisory]. National Academy of Sciences website. Published November 8, 2011. Accessed December 3, 2015.

19. DeJong C, Santa J, Dudley RA. Websites that offer care over the Internet: is there an access quality tradeoff? JAMA. 2014;311(13):1287-1288.

20. Bishop TF, Press MJ, Mendelsohn JL, Casalino LP. Electronic communication improves access, but barriers to its widespread adoption remain. Health Aff (Millwood). 2013;32(8):1361-1367.

21. Claxton G, Rae M, Panchal N, et al. Health benefits in 2013: moderate premium increases in employer-sponsored plans. Health Aff (Millwood). 2013;32(9):1667-1676.

22. Hsu J, Price M, Brand R, et al. Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study. Health Serv Res. 2006;41(5):1801-1820.

23. Selby JV, Fireman BH, Swain BE. Effect of a copayment on use of the emergency department in a health maintenance organization. N Engl J Med. 1996;334(10):635-641.

24. Reed M, Fung V, Brand R, et al. Care-seeking behavior in response to emergency department copayments. Med Care. 2005;43(8):810-816.

25. Huskamp HA, Deverka PA, Epstein AM, Epstein RS, McGuigan KA, Frank RG. The effect of incentive-based formularies on prescription-drug utilization and spending. N Engl J Med. 2003;349(23):2224-2232.

26. Joyce GF, Escarce JJ, Solomon MD, Goldman DP. Employer drug benefit plans and spending on prescription drugs. JAMA. 2002;288(14):1733-1739.

27. Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA. 2001;285(4):421-429.

28. Soumerai SB, Ross-Degnan D, Avorn J, McLaughlin T, Choodnovskiy I. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. N Engl J Med. 1991;325(15):1072-1077.

29. Goldman DP, Joyce GF, Escarce JJ, et al. Pharmacy benefits and the use of drugs by the chronically ill. JAMA. 2004;291(19):2344-2350.

30. Hsu J, Price M, Huang J, et al. Unintended consequences of caps on Medicare drug benefits. N Engl J Med. 2006;354(22):2349-2359.

31. Piette JD, Heisler M, Wagner TH. Cost-related medication underuse among chronically ill adults: the treatments people forgo, how often, and who is at risk. Am J Public Health. 2004;94(10):1782-1787.

32. Tseng CW, Dudley RA, Brook RH, et al. Elderly patients’ preferences and experiences with providers in managing their drug costs. J Am Geriatr Soc. 2007;55(12):1974-1980.

33. Chen C, Garrido T, Chock D, Okawa G, Liang L. The Kaiser Permanente Electronic Health Record: transforming and streamlining modalities of care. Health Aff (Millwood). 2009;28(2):323-333.

34. Goldzweig CL, Orshansky G, Paige NM, et al. Electronic patient portals: evidence on health outcomes, satisfaction, efficiency, and attitudes: a systematic review. Ann Intern Med. 2013;159(10):677-687.

35. MacPhail LH, Neuwirth EB, Bellows J. Coordination of diabetes care in four delivery models using an electronic health record. Med Care. 2009;47(9):993-999.

36. Graetz I, Reed M, Shortell SM, Rundall TG, Bellows J, Hsu J. The next step towards making use meaningful: electronic information exchange and care coordination across clinicians and delivery sites. Med Care. 2014;52(12):1037-1041. 
Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up