Only 9.2% of outpatient visits in the United States in 2001, 5.8% in 2002, and 5.5% in 2003 were to physicians who engaged in internet or e-mail consults. This represents one of the largest published studies of the availability of physicians who do internet or e-mail consults to date. Similarly, large studies have been done by private research firms,5,9,10
but no previous published study included patient, provider and visit-level characteristics.
The proportion of visits in which patients saw providers who reported doing internet or e-mail consults is similar to other studies, although results are difficult to compare as the question wording differs.4–8,10,21
Gaster and colleagues observed that 72% of academic physicians averaged 7.7 e-mails to patients each month.22
Hobbs and colleagues observed that 75% of academic physicians exchanged e-mail, but most with only 1–5% of their patients.7
Brooks and colleagues observed that 16.6% of physicians in Florida exchanged e-mail with patients, but less than 3% did this on at least half of all business days.21
Surveys by DeLoitte and Manhattan research observed that 25% of physicians reported e-mailing patients, though frequency was not noted.9,10
Surveys of patients have observed lower rates. Moyer, Sittig, and Fox and Jupiter Research, respectively, observed that 10, 6, 7, and 3% of individuals had ever e-mailed a doctor.2,4,6
The current study, however, examined internet or e-mail “consults”, rather than simply exchanging e-mail with patients. A study by Jupiter research, which similarly described the activity as a “consult”, observed that only 3% of adults with internet access reported having online clinical consultations with their doctor in 2003.5
The main observation was the low overall rate in the proportion of visits to providers who reported doing internet or e-mail consults and lack of an increase in the rate. The lack of an increase between 2002 and 2003, years in which the question wording was consistent, is somewhat surprising given the simultaneous growth in internet access and online health information seeking.2,3,23,24
This may be because of the looming implementation of the Health Insurance Portability and Accountability Act25,26
in 2003 and the lack of secure online communication tools and health plan reimbursement at the time.15,27,28
Access to providers who conducted e-mail consults was higher among male patients, though the reasons for this are not clear. Adjusting for whether or not the provider was an obstetrician gynecologist did not remove the gender difference. Although NAMCS now collects provider demographic information, the NAMCS in 2001–2003 did not, so we are unable to test whether these differences are due to demographic differences in the providers seen by men and women. Also, patients who saw primary care providers and patients seen for pre-/postoperative care were more likely to see a provider who conducted internet or e-mail consults. Primary care providers, whose practice includes a significant amount of chronic disease management, may find e-mail helpful for streamlining communication with patients.13,29
Similarly, physicians whose practice includes a significant amount of pre-/postsurgical care may find e-mail useful for patients; they may not be seeing the patient on an ongoing basis to send laboratory results.8,30
It is somewhat surprising that the number of medications was not associated with likelihood that the patient saw a provider who did e-mail consults, as one important use of e-mail is medication refills.8
This indicates that patients using more medications were not more likely to seek out such providers, perhaps because other factors are more important influences on choice of provider. Although it was reassuring that access to physicians who did internet or e-mail consults did not differ among patients of differing insurance status, access to these physicians was less among minority patients. The NAMCS did not include data regarding patient education level or household income, so residual confounding cannot be excluded.
Our analysis had the following strengths: (1) the sample was nationally representative and multiyear and (2) patient-, visit- and provider-level data were included. The results should be interpreted with the following limitations. First, there is no clear definition of a “consult” via internet or e-mail, given that these technologies are still evolving. As reimbursement is likely to increase the use of these more formal “consults”, future studies will be needed to assess the impact and comparability to face-to-face services, as has been done to compare primary care physicians and primary care nurse practitioners.31
Second, although certain patients were more likely to see a provider who engaged in internet or e-mail consults (e.g., men), we do not know whether these patients were more likely to engage in an internet or e-mail consult with their provider. This is a limitation of the data, as physicians were only asked once, not after every visit, whether they engaged in internet or e-mail consults. Third, we could not examine some patient (e.g., household income) and doctor (e.g., age) characteristics that may be related to whether doctors conduct internet or e-mail consults. We do not believe that these limitations are likely to impact the main findings of the study that internet or e-mail consult rates were generally low and did not appear to be increasing, despite strong growth in other internet-related health activities.