Survey data demonstrate that more than two-thirds (69%) of adults living in the United States use a computer, with 51% reporting use at home, 47% reporting use at work, and 26% reporting use at a college, library, or other location.1
These computer users spend an average of 15 hours per week on their computers, with an average of six hours per week spent using the Internet. Approximately 126 million adult Americans (63% of the U.S. adult population) use the Internet, with 87% having access at home and 48% having access at work. Approximately 102 million Americans use e-mail, and 52 million use instant messaging.2
Of particular significance in health care, the number of Americans aged 65 and older who used the Internet increased by 25% to almost 10 million.3
The number of women age 65 and older who used the Internet grew faster than any other group, with an increase of 30% to 4.6 million users in 2003, whereas the number of male Internet users over 65 increased by 20% to 5 million. Those in the 55 to 64 age range increased their numbers by 15% to almost 16 million. In comparison, Americans aged 35 to 49 and 25 to 34, who represent the largest number of Internet users, only experienced year-to-year increases of 1% and 3%, respectively.3
Survey data reveal that the majority of physicians use a computer or the Internet for business or personal reasons. In a 1998 survey by the American College of Physicians–American Society of Internal Medicine, 82% of the physicians were using computers. Of these, 67% of the physicians who had the technology to connect to the Internet at home used it on a weekly or daily basis, and 69% used it at the office on a weekly or daily basis.4
In the office, 58% of physicians reported using the computer daily for e-mail, yet only 7% reported using e-mail daily or weekly to communicate with patients. At home, the findings were similar: 69% of physicians reported using the computer daily or weekly for personal e-mail, but only 2.6% reported using it to communicate with patients. In another survey conducted by the American Medical Association, 70% of physicians said they were using the Internet, whereas 25% were using e-mail to communicate with their patients.5
In a more recent survey by Harris Interactive, 93% of physicians reported using the Internet, with 87% reporting use at home, 56% in their offices, and 40% in the clinical work area.6
Fifty-five percent of practicing physicians used e-mail to communicate with professional colleagues, and 34% used e-mail to communicate with their support staff. However, only 14% of physicians used e-mail to send patient-specific clinical information (e.g., clinical consultation with another physician, prescriptions), and only 13% of physicians communicated with their patients by e-mail.
As health care continues to evolve to a more patient-centered approach, patient expectations and demands will be a major force in driving the use of electronic communication. Many patients are interested in using e-mail to communicate with their physicians and are interested in receiving online health information from their doctor's office.7,8,9
In one study, 81% of the online population said they would like to receive e-mail reminders for preventive care, 83% said they would like to receive follow-up e-mails after visits to their doctors, and 84% said they would like their doctors to be able to access and monitor their laboratory tests online.10
In addition, many of the study participants expressed frustration before, during, and after they saw their doctors. For example, 60% said they forgot to ask all their questions, 41% expressed frustration because they had to see their doctor in person to ask questions that could have been answered by telephone or e-mail, and 35% were concerned about getting through to someone who could answer their questions.
For both patients and providers, Web messaging, in which commonly occurring types of messages (such as requests for appointments) are prestructured and directed to the appropriate recipients (e.g., scheduling personnel) offers many potential advantages. The asynchrony inherent in electronic communication allows users to send and read messages at their convenience and alleviates the problem of multiple handoffs and engaging in “telephone tag.” Electronic communication also allows the user to document, track, and verify that messages were sent and received and distribute or link to educational materials and other resources. Electronic communication can also be stored electronically or printed out for personal record keeping and future referral (e.g., instructions for taking medication).
For increasing numbers of patients and providers, Web messaging linked to a patient EHR is likely to become the preferred communication channel for routine clinical communications (e.g., reporting home blood pressures and adjusting medical regimens, renewing prescriptions, managing administrative activities such as scheduling). It shares the convenience of asynchrony with standard e-mail. It can be conveniently stored as part of the patient's EHR. It has the potential to be more efficient for both patients and providers than telephone, letters, in-person visits, or even standard unstructured e-mail. It is also more secure than telephone, standard e-mail, or U.S. mail.11
There are limited data in the peer-reviewed literature on the use of electronic communication in health care. Most of these articles consist of guidelines for the use of electronic communication12,13,14
; surveys on attitudes about the use of electronic communication, mostly by patients and clinicians who are not actually using electronic communication4,8,15,16,17,18,19
; and patients' experiences and attitudes about having electronic access to their medical records, most of which come from the United Kingdom.20,21,22,23,24
In a recent study, Liederman et al.25
evaluated the use of Web messaging in a primary care clinic affiliated with the University of California, Davis, that involved eight clinicians, nine medical assistants, four clerical staff, 869 enrolled patients, and 238 survey respondents. More than 85% of patients were satisfied with the use of the Web-messaging system, 88% found it easy to use, 78% thought it improved access to their provider, and 79% said it was better than calling their providers on the phone. Because of the small number of clinicians involved, it is difficult to draw conclusions from their provider survey. However, 62% thought that it improved communication between them and their patients, 75% of them said that they would be “somewhat likely” or “very likely” to keep using the Web-messaging system after completion of the study, and 75% of them stated that it was important that they be reimbursed for the time spent communicating with patients online.
Despite the potential benefits of Web messaging, there are also potential drawbacks. One is that it provides a less robust means of communication, which can result in missing not only the visual/audio cues of in-person contact and audio cues of telephone calls but also the interactivity of real-time communication. This makes Web messaging less appropriate for complex and sensitive topics. For example, although Web messaging may be well suited for patients communicating with their providers about home blood pressure measurements or renewing prescriptions, it may be less appropriate for discussing complex issues such as whether a patient should undergo prostate cancer screening, informing a patient about a new chronic condition, or discussing complicated medical management issues. Other concerns include the fact that Web messaging is not appropriate for urgent medical issues, it might threaten patient privacy and confidentiality, it might disrupt current clinical workflow and increase provider workloads, it might decrease office visits and revenue, it is not reimbursed, it might expose providers to increased liability, technical infrastructure and support might be expensive and difficult to provide, and the art of medicine might be marginalized. The American Medical Association and American Medical Informatics Association have developed guidelines for e-mail communication between physicians and patients that address some of these issues.12,13,14
Despite these concerns, there is considerable interest among patients, providers, payers, and policy makers in understanding how patient access to their electronic health record (EHR) and Web messaging can be optimally integrated into health care delivery to improve safety, quality, and efficiency. In an attempt to shed light on some of these issues, we conducted a study of patients who were early adopters of a patient EHR and Web messaging to learn more about their experiences and attitudes.