We evaluated use of a secure messaging within the context of an integrated group practice using an advanced electronic health record system and identified significant variability according to individual patient characteristics. Greater overall morbidity was the strongest predictor of patients’ use of SM. These results contrast with prior research among patients with chronic conditions demonstrating lower use of the Internet27
use of electronic messaging with providers. Although these former studies suggest that electronic communication between patients and providers reflects some of the same patterns as overall Internet use, including higher use among the younger population and those living in metropolitan areas30,31
, they may not reflect the pattern of SM use when it is widely offered by providers. A 2008 survey reported that 90% of all patients online want to be able to e-mail providers32
. Yet, in 2003, only 5.5% visits were to providers who reported doing Internet or e-mail consultations29
. In most healthcare settings, providers remain concerned about the lack of reimbursement, increased workload, and insufficient security associated with patient e-mail2
In the current study, all patients and providers were actively encouraged to use SM. Group Health’s SM access and online shared medical record with patients were part of a larger organizational redesign focusing on patient-centered access. This organizational commitment, including provider incentives to engage in SM, may have contributed to greater use of SM for follow-up and proactive care of patients with chronic conditions33–35
. Despite the uniform organizational commitment, primary care providers had widely differing amounts of SM with patients (2.8% to 52% of SM outpatient encounters). This variable participation in SM by primary care providers was an independent predictor of whether a patient used SM. Differences between provider panels did not account for this variation. Other characteristics of physicians and patients not evaluated in this study are likely influencing whether patients and physicians engage in SM.
Patients had a few other important differences in SM use. Patients with Medicaid insurance and those over the age of 65 years were less likely to engage in SM. Most importantly, Internet access does not appear to entirely account for this difference in SM use. Even when these populations had registered for the patient Website, they used SM less compared with those who were younger or had commercial insurance. Patients with low neighborhood SES were also less likely to use SM in the analysis comparing SM users to patients not registered for the Website. Since census measures of SES are poor predictors of individual income and education in the Group Health population36
, less SM use among patients living in low SES neighborhoods may be due to differences in the resources available to these communities, such as broad band internet access. Future work should clarify the factors—such as health literacy, technical literacy, patient activation, broadband Internet access and physical disability—that may account for these differences13,14
. Because many elderly patients and those on Medicaid live with chronic conditions, understanding how electronic communication interacts with known disparities in access to care is critical.
Our study has several limitations. Because the study used only automated data, several factors important for assessing Internet access were not available, such as individual-level socioeconomic indicators, physical disability, health literacy, technical literacy, and race/ethnicity13,14
. The cross-sectional design also limited the ability to ascribe causality; patients who want to engage online may have selected providers that would engage online. Although the demographics of the Group Health population are similar to the surrounding area, the results of our study may not be generalizable to other health care systems. SM was studied during a period of rapid adoption. In 2004 alone, Group Health doubled the number of patients engaging in SM with providers. Future evaluations with a similar study design may yield different results. Provider incentives for SM may also limit the application of our results to other systems that use different financial incentives for electronic encounters. SM was also available in the context of a patient Web site with a shared online medical record between patients and providers. This constellation of online services and personal health information may have attracted a particular population of patient users. Last, phone calls with patients were not included in the primary care providers’ measure of total outpatient encounters. Future studies should include all contact with patients: those in person, over the phone, and through electronic messaging.
In this integrated group practice, patients living with greater overall morbidity were the most active users of patient–provider SM. These findings support the potential role of SM in the Patient-Centered Medical Home37
and the Institute of Medicine’s vision for redesigning health care1
. Future studies should clarify variation in access to and use of SM as well as its impact on the cost and quality of care received.