Even if university students do not represent the whole population, they can act as "pilot population" representing adults of working age of a future information society. Our study population – doctors taking care of students – was small with only 52 respondents. Thus the results of the study cannot be indiscriminately generalized. Because of the small study population comparison of the subgroups may not be reliable.
Although the study group was small, it well represented all the doctors at the FSHS, and the response rate was high. A further strength was that we compared the number of patient contacts documented in the questionnaires during the study week to the statistical data of contact numbers from the EPR at the same time. In other studies no corresponding comparison has been made.
The doctors were asked to keep a daily tally of visits, phone calls and email messages, and to evaluate how many visits or phone calls could have been replaced by email. Many doctors undoubtedly did this simultaneously with patient work. Some doctors might have been in a hurry, they probably supplemented the questionnaire at the end of the day. To achieve a more accurate evaluation of visits and phone calls replaceable by email, a continuous assessment (visit by visit, phone call by phone call) could have been stressed even more in the instructions.
The doctors at the FSHS do not have a specific electronic communication system focused on patient communication. They use their general, unprotected email system also to communicate with patients. A specific communication system used only for patient communication would enable an automatic collection of the patient communication data and create a more accurate database than our data collection method.
Katz and colleagues have made the only controlled and randomized study concerning physicians' use of email [5
]. Our own results on the average number of doctors' email contacts and email usage are of the same magnitude as those referred to above and in other recent studies in the USA [4
]. In the present study 79% of respondents used email for patient communication. The proportion of those who had used email is clearly larger than in older studies, and at the same level as reported in recent international studies [2
Our study revealed individual differences in the use of email in patient work. Differences in physicians' activity in using email have previously been reported in only one study [4
]. Deriving of our small study group only especially glaring association between subgroups of respondents could be verified. Our findings still support the results published by Gaster and associates. Physicians working in the capital area were more active email users than their colleagues elsewhere in Finland.
Physicians reckoned that email could replace only 2% of visits. This confirms Sittig's evaluation in 2003 that email could possibly cover a small percentage of visits [10
]. Increasing the use of email can thus not considerably reduce the number of patient visits. On the other hand it could make physicians' crowded telephone hours easier [15
When we compared contacts in the EPR with contacts registered daily on the questionnaires we found that the majority of email contacts were not registered in the EPR. This finding is supported by Gaster and colleagues who asked physicians themselves to describe how often they usually registered email contacts in patient records [4
FSHS provides specific electronic services for focused issues (email service for cancellation of appointments, health counseling service on the Internet, and email service for feedback). Principles of recommended issues to use email between health providers and patients are available for students at FSHS' websites. We have had a presumption that email messages between FSHS' physicians and their patients mainly handle patient care. Nyström's congress report from 2004 supports our presumption. He explored 139 email messages from 103 individual patients at his GP practice at the FSHS and noticed that 77 % of email messages handled medical tests, and 16 % handled follow-ups of symptoms or illnesses [16
]. Thus the information in email communication should be entered in patient records.
All university students in Finland have access to Internet and email at their universities. Use of email as communication method in health care does not in their case cause inequalities in health. A general tendency in the societies to provide also health services widely in electronic form (in Internet or by email) can contribute to inequalities for those who are not able to use modern technologies [13