Electronic communication holds the potential to enhance the patient-physician relationship and quality of care by expanding the opportunities for patients and physicians to interact [8
]. Older patients would likely benefit most from electronic correspondence with their physicians. We found that nearly half the patients surveyed were indeed enthusiastic about using email with physicians. Enthusiasm to use email was affected by several factors that may have significant implications for future research, clinical practice, and policy decisions.
First, even though overall use of email with health care providers was low, older patients and especially non-whites were likely to adopt this technology if given the opportunity. Our findings strongly suggest consideration of email as a medium to overcome communication barriers affecting this population. Public interest in and demand for expanding the use of this technology in the senior population [17
] could have significant implications for reimbursement policies. Some insurance carriers reimburse physicians for certain types of email, and the American College of Physicians advises Medicare to reimburse selected use of email [21
]. Enthusiasm for email use is likely to grow with increasing access to the Internet and might provide a basis for future reimbursement-related policy changes for the Medicare population.
Second, our study suggests that the patient-physician relationship is relevant in determining patient enthusiasm to use email with a physician. Our study supports findings from a recent study which found that certain aspects of the patient-provider relationship affected interest in the use of computerized patient portals [22
]. Consistent with previous research, increasing age and less familiarity with technology were negatively related to enthusiasm [17
]. Although we found that enthusiasm to use email among older adults decreased with increasing age, it still remained relatively high overall.
Third, we noted two unexpected findings related to demographics. First, subjects with self-reported poor health status were not highly enthusiastic about using email, contrary to findings reported in previous literature [13
]. Second, we found that non-white patients were more enthusiastic than white patients about using email, also in contrast to previous findings [13
]. Because non-whites generally receive less positive talk (positive talk includes more verbal behavior, agreements, encouragement, and reassurance) and information even within the same medical practice [23
], their use of email may overcome some of the communication barriers they face. Being a less socially intimidating forum, an electronic medium could bolster the quality of patient-physician communication, since it might encourage older adults to ask questions and provide vital information more readily than during face-to-face communication [14
]. This may be especially relevant in older men; men in general ask fewer questions, receive less positive talk, and are less likely to be included in discussion than women [23
]. These reasons may explain why older men are more enthusiastic about using an alternative medium such as email to communicate with physicians.
Adoption by older patients of email as a tool to communicate with their physicians might also depend on the attitudes and beliefs of physicians and the value they place on communicating electronically. Previous work shows the criteria applied by physicians to use email remain subjective and depend on factors besides patient barriers (eg, a patient’s access to the Internet), such as reimbursement for time spent writing email [3
]. Although physician characteristics, such as demographic [5
] and time and place of training, and practice characteristics, such as the setting and availability of a practice website, were expected to affect enthusiasm for email use, our findings did not substantiate this expectation. The quality of patient-physician communication may also be affected by a physician’s morale and job stress [26
]. Physicians dissatisfied with their careers cite problems in relationships with their patients and difficulties in caring for them, in addition to problems in communicating with specialists [27
]. We expected these physicians to have less enthusiasm for using email but found quite the opposite. A partial explanation for this could be that these physicians found the prospects of an alternative medium of communication with patients especially valuable in addressing problem areas of communication within their practices. Furthermore, both confidentiality issues, such as those posed by HIPAA,and reimbursement-related issues pose additional barriers which dampen physician enthusiasm [7
]. For example, physicians may have concerns that email will be too time consuming and not worth their time if they are not compensated [28
Our findings also have implications for strategies to improve the use of email by older patients and their physicians. Availability of the Internet through community resources and efforts to engage family members in the process could significantly affect the use of email by older patients whose access to technology may be limited. Physician enthusiasm could be increased by having continuing medical education programs on electronic communication with a focus on specific barriers noted by physicians (eg, HIPAA limits).
Our study has certain limitations. Our analysis was based on a cross-sectional secondary look at existing data, and data on certain factors that could have played a role in determining enthusiasm (eg, use of email by other family members, reimbursement to physicians) were not collected at the outset. Secondly, while patient enthusiasm may be higher now than it was in 2003, factors determining patient enthusiasm are likely not to have changed dramatically. Our strengths include a large sample size drawn from a large, populous area; a diverse population that is representative of the region; and the inclusion of both genders. We also have a wide representation of primary care with diverse sets of physicians.
In conclusion, our study lends support to our hypothesis that, in addition to factors related to patient demographics and familiarity with technology, enthusiasm to use email depends upon the quality of existing relationships between patients and physicians. We found that older patients, especially non-whites, are highly likely to adopt this technology, but that factors arising from their interactions with physicians in traditional face-to-face encounters or their physician’s interest in the use of email could adversely affect their interest. Significant opportunities exist to use electronic tools to overcome some communication barriers affecting older patients. Further study on whether the adoption of email can reduce communication-related health disparities in the older non-white population is warranted. Public interest and demand in expanding the use of email could potentially lead to changes in reimbursement policies concerning the use of email.