In this randomized controlled trial, patients with access to an Internet-based patient portal were more satisfied with their communication with the clinic and their overall care. These patients were also more satisfied with clinical messaging with their physicians and the process of requesting appointments, prescription refills, and referrals. Patients were more likely to send FYI and psychosocial messages via the portal than by telephone. The volume of incoming messages was minimal: 1 message daily for every 250 patients offered online access. Portal and control group clinical message volumes were not significantly different.
Why were portal patients more satisfied than controls? First, the portal was convenient: 81% believed that the portal saved them a telephone call, and 33% believed it saved them a visit to the clinic. The portal allowed patients to send messages at all hours; indeed, 73% of incoming messages were sent during nonclinic hours. Second, the portal reduced barriers to communication—portal patients were more likely to send FYI and psychosocial messages. Patients may hesitate to “bother the doctor” with FYI messages by phone, but they feel more comfortable sending a portal message. Patients may prefer sending psychosocial messages by portal because it affords privacy and distance, avoiding the aggravation of being on hold and having to speak to an intermediary. One patient even suggested to the physician that the portal was a more comfortable medium for psychosocial discussion than in-person visits. Third, patients may have appreciated that portal messages were more likely to receive direct responses from the physician, whereas telephone calls tended to be mediated by a triage nurse. Finally, the portal was efficient, providing quick message responses that likely exceeded patient expectations. A substantial majority of messages were answered the same day, even though the portal states that responses may take up to 2 business days. This is consistent with other studies that demonstrated improved patient satisfaction with shorter response time [11
] and with meeting or exceeding patient expectations [16
It is clear that patients increasingly desire and are satisfied with online messaging. Physicians are much less enamored with electronic communication, driven by fears of overwhelming volume, inappropriate messaging, and inadequate security [5
]. The increasing publicity of patients demanding such service, the lack of demonstrated adverse effects, and the possibility of insurers reimbursing physicians for online communication may narrow this satisfaction gap [8
In our sample, the total number of incoming messages from portal patients (portal plus phone) was not significantly different from the total number of incoming messages from controls. This implies that patients replace phone calls with electronic messages. Although Katz et al [5
] showed that total message volume increases with patient access to online messaging, others have shown a replacement of phone calls with online messages [4
]. Although not specifically measured, both physicians and staff noted that responding to electronic messages took less time than responding to telephone messages, even after discounting the frustration of “telephone tag.” Others have corroborated this finding [18
Portal patients called more times than they sent online messages. Why? Urgent calls were one third of the phone call volume. Subtracting urgent calls, portal patients were equally likely to call as they were to send an online message. Adopting a new communications medium may occur gradually, with patients not trusting the new system, forgetting how to access it, or not thinking to use it.
The clinical utility of incoming messages is beyond the scope of this study. It is not clear, for example, how FYI messages might have impacted care. At worst, one might imagine such messages “cluttering” the patient’s medical record. At best, it might “close the loop” when patients inform their physician of the success or failure of a treatment. Although we demonstrated improvement of patient satisfaction, we are unable to state whether quality of care was affected.
Portal group patients who never used the system were similar to controls in their satisfaction with clinic services, except that they were more satisfied with “overall communication.” These patients may have felt that simply having the portal available if they needed it was advantageous.
Some organizations are charging patients for portal clinical messaging. Since 53% of study participants would not pay for portal messages, this could shift portal messages to “free” telephone calls, reduce FYI and psychosocial messages, and affect satisfaction. Notably, some insurers are beginning to reimburse physicians for online communications, which may partially address this concern [8
This study has several limitations. Control group patients who continued emailing their physician may have diluted the difference between groups. Our patients had relatively high incomes, educational status, and familiarity with the Internet, and one third were University of Colorado or Health Science Center employees, so these results may not be generalizable to an Internet-naive, less affluent sample. Because of the nature of the intervention (online messaging vs telephone calls), the physicians and staff could not be blinded to the process and may have paid more attention to online messages, influencing the results. The study was conducted for only 6 months; patient satisfaction could have increased (due to increased familiarity) or decreased (due to fading of initial enthusiasm) if the study was carried out over a longer period of time. We note that our final sample size (N = 95 actual users) was smaller than our desired size of 150. We reported that the portal group achieved higher satisfaction than controls for “overall care” (P = .04). A larger sample would have provided a more precise estimate of effect. Lastly, because of our recruitment method, we were unable to collect information from patients who were eligible for the study but declined to participate. Despite initial randomization of patients and comparable demographic characteristics in dropouts, those who dropped out of the portal and control groups may be different, biasing the results of the final survey.
Summary and Future Directions
This randomized controlled study adds to the literature by describing possible underlying reasons for patient satisfaction with online communication: convenience, reduced communication barriers, and direct physician responses. Another novel finding was that more online messages from patients contain FYI and psychosocial content compared to telephone calls. These findings may explain why patient access to an Internet-based patient portal was associated with greater patient satisfaction with communication and overall care.
A patient portal that supports online communication is a strong foundation on which to promote “care based on continuous healing relationships” [1
] and encourage collaborative care. Further research is needed to evaluate more advanced portal services and their impact on patient satisfaction, empowerment, and medical outcomes. An advanced patient portal might include shared documentation by physicians and patients, patient access to test results and other aspects of their medical record, and shared decision support to patients and physicians for chronic care improvement.