Background: Patients want electronic access to providers. Providers fear being overwhelmed by unreimbursed messages.

Objective: Measure the effects of patient-physician web messaging on primary care practices.

Design/Setting: Retrospective analysis of 6 case and 9 control internal medicine (IM) and family practice (FP) physicians’ message volume, and a survey of 5,971 patients’ web messaging with 267 providers and staff in 16 community primary care clinics in the Sacramento, CA region.

Measurements and Main Results: Case telephone volume was 18.2% lower ( P= .002) and fell 6.50 times faster than control. Case total telephone plus web message volume was 13.7% lower ( P =.025) and fell 5.84 times faster than control. Surveys were responded to by 40.3% (1,743/4,320) of patients and 61.4% (164/267) of providers and staff. Patients were overwhelmingly satisfied and providers and staff were generally satisfied; both found the system easy to use. Patient satisfaction correlated strongly with provider response time (Γ=0.557), and provider/staff satisfaction with computer skills (Γ=0.626) (Goodman-Kruskal Gamma [Γ] measure of ordinal association).

Conclusions: Secure web messaging improves on e-mail with encryption, access controls, message templates, customized message and prescription routing, knowledge content, and reimbursement. Further study is needed to determine whether reducing telephone traffic through the use of web messaging decreases provider interruptions and increases clinical efficiency during the workday. Satisfaction with web messaging may increase patient retention.

Effective communication between patients and physicians improves health care quality.[1] Poor communication can lead to increased patient stress,[2] decreased satisfaction,[1,3] decreased adherence,[4,5] and elevated malpractice risk.[6] Face-to-face contact is not necessary for effective communication. Fifteen percent to 28% of all ambulatory medical contacts are made by telephone[7,8] and 70% of these encounters can be managed without the physician ever seeing the patient.[9]

E-mail does not require patients and providers to be available concurrently. Such asynchronous communication avoids “telephone tag” and the interruptions associated with telephone calls.[10–12] Telephone messages are often overlooked, misplaced, or transcribed incorrectly. E-mails are less likely to be lost, do not require transcription, and can be printed or attached to the chart.[10,11] Recognizing these advantages, the Institute of Medicine calls electronic patient-provider communication a core functionality of an electronic health record.[13]

Internet access has greatly increased in recent years. Of the 67% to 78% of U.S. adults with Internet access, [14–16] 90% want to communicate with their physicians electronically.[17] Of these, 56% say it would influence their choice of physician.[17] Physicians are far more reluctant. Although 89% of physicians have Internet access,[18] only 13% to 21% communicate with their patients by e-mail.[19,20] Several barriers to adoption can explain this low rate. Few payers reimburse for online patient care,[17,21,22] although the American College of Physicians, among others, has advocated that Medicare do so.[22] Security concerns are another barrier. Many physicians and patients report reluctance to use unencrypted e-mail that could be intercepted by unauthorized individuals.[23–25] Physicians also fear being overwhelmed by patient e-mails.[11,17,23–26] Katz et al. found e-mail increased the communication burden on physicians and staff, and concluded e-mail did little to improve the efficiency and effectiveness of clinical care.[27] Potential liability due to missed diagnosis or delayed treatment of acute problems is another barrier.[10,24] In addition, patients cite slow response times by their physicians as a concern, especially when an urgent response is needed.[23,26,28,29]

Secure web messaging is structured, encrypted communication via common web browsers such as Internet Explorer and Netscape, which improves upon the inherent weaknesses of e-mail.[30] Web messaging can control access and safeguard privacy with userIDs and passwords for providers, staff, and patients.[30,31] Structured forms can generate concise messages, which improve efficiency, and automated message routing to appropriate staff can reduce physician workload.[30,31] Patient fees and copayments can be paid by credit card.[30,31] The health industry has been slower to adopt web messaging technology than other service industries such as online retail and banking.[31]

Several studies report positive results with e-mail and/or web messaging between patients and their providers. Parents, guardians, and pediatric gastroenterologists found that e-mail was faster and more convenient than telephone consultations.[32] Penson et al. conclude e-mail within an established doctor-patient relationship increases patient satisfaction and doctor-patient communication.[33] A recent pilot study of web messaging at a primary care clinic found 79% of patients and 61% of physicians preferred it to telephone use.[30]

This study examines how a commercial web messaging system affected patient, provider, and staff satisfaction, and provider message volume. From a pilot study,[30] we hypothesized that: 1) patient satisfaction would be high and would correlate with message response time; 2) provider/staff satisfaction would be mixed and would correlate with ease and frequency of system use; 3) incoming patient message volume would not differ between sites using and not using patient web messaging; and 4) telephone call volume would decrease at the site using web messaging.