The use of secure messages between doctors and patients is increasing, thanks in part to the meaningful-use
requirements for electronic health records. But the fee-for-service model may be preventing more widespread adoption, experts contend. Another challenge is cultural. Doctors—and patients—aren't necessarily accustomed to regularly exchanging messages.
Roughly 41% of hospitals were able to send and receive secure messages in 2013, show data from HHS' Office of the National Coordinator for Health Information Technology.
The Center for Disease Control and Prevention's National Center for Health Statistics found similar numbers among physicians: About 40.4% say they'd used it, with 8.4% saying they had the function, but hadn't really used it.
One of the core requirements for Stage 2 of meaningful use is that 5% or more of unique patients must send a secure message to their providers. Athenahealth
, a cloud-based EHR
vendor, reports that as of March 31, 33% of its physicians were able to attest to using secure messaging.
Athenahealth and its physicians are finding culture, defined broadly as how offices function, to be an issue in adoption, said Rhian Gregory, senior manager of product marketing.
“For example, it's about making sure your front-office staff is routinely collecting e-mail addresses for every patient when they come in, and then making sure they're actually sending out invitations to register for the portal, to get them more engaged,” she said. “There's some outreach there, some give-and-take,” noting that providers also have to change the terms they've been using—“send me a message” as opposed to “give me a call” during consultations. Kaiser Permanente
received approximately 8.2 million secure e-mail messages in 2013, with the numbers of messages growing by almost 20% per year on average. The system's vice president of health IT transformation and analytics, Terhilda Garrido, thinks the recent introduction of a mobile app will continue that expansion.
E-mail messaging has been helpful for Kaiser in a few areas: higher satisfaction, better quality, and improved logistics.
A 2013 internal survey found that new members of Kaiser Permanente Northern California using secure messaging had higher satisfaction rates, and were more likely to re-enroll, according to a February Health Affairs
article examining Kaiser's secure messaging experience.
Garrido thinks patients may be substituting secure messaging for traditional office visits in two categories. The first: low-acuity conditions—such as a cough, rash or urinary tract infection—where there isn't a follow-up office visit for around 85% to 90% of cases initiated by e-mail, Garrido says. The effectiveness of such messages has increased with new capabilities for attaching pictures to messages—so a patient can send a picture of a rash, for instance, to the doctor.
The other is with chronic conditions, where patients can check in instead of making an appointment, though Garrido cautions “that, we're still trying to understand.”
What's stopping greater adoption? A health plan executive interviewed for an August 2013 Health Affairs study—joined by others interviewed—said one issue is that of reimbursement for messaging, which is low or nonexistent.
In an interview, Dr. Tara Bishop, the author of the study and an internist and researcher at Weill Cornell Medical College, identified fee-for-service as a barrier to adoption, but added that the pressures of payment reform and meaningful use would nudge systems into relying more on messaging. But, she added, physician workload and cultural factors also play a role.
“One of the things we did find is it didn't necessarily lighten the workload of physicians,” she said. “From a per encounter standpoint, it is much more efficient. I personally can send off a secure message and have a secure message conversation in much less time than it takes to call them or have them come into the office. … You don't have to have someone sitting by the phone and play voicemail tag.”
But, she suggested, the ease of messaging can become an “onslaught of communication” that often ends up overwhelming physicians.
Garrido said that Kaiser's clinics and hospitals have dealt with the same issue, with one popular solution being a scheduled half-hour of “desktop medicine time” for each half day of work.
“It creates a little bit of space,” Garrido said.
Bishop said that in her observations, some organizations “encouraged (patients) to manage things … through e-mail and secure messages.”
Adoption by various ethnic groups has been challenging at Kaiser, Garrido said. While she hopes, in the future, that the system's new mobile app will improve access for people of color and the elderly, that hasn't been the case so far. While around half of the users of kp.org, the main portal, are 50 or older, on mobile, only 15% are.
The system is conducting focus groups with African-Americans and Latino Kaiser Permanente members, who have aired concerns that the mobile site's registration process is too cumbersome. They're also concerned with security, Garrido says, and the sense that secure messaging might not be complementary but rather replace face-to-face time with doctors.
They don't “want to get less of the physician's time and attention,” Garrido said. “And we need to clarify this is complementary care, that this is, of course they can choose to reach out and make an appointment whenever they want to.” Follow Darius Tahir on Twitter: @dariustahir