Electronic Healthcare Communication
Electronic healthcare communication in patient-physician interaction may facilitate better care for patients and more efficient practice for physicians.
eHealth interactions has the potential to reduce prevalent overload experience, reduce consumption of higher-cost in-person services, and strengthen physician-patient relationship through the more affordable, convenient and immediate access eHealth services encompass.
According to a recent study by the California HealthCare Foundation, up to 77% of healthcare consumers desire to interact with their physicians online (1). A 2006 Gartner study reports that over 85% of physicians are looking to streamline their operations using the internet, and 90% of providers see the internet as a way to gain a competitive advantage (2).
E-mail is the most common and accessible asynchronous electronic interaction channel, though latest interactive technologies such as digital telephony, video conferencing and healthcare 2.0 platforms continuously expand eHealth communication tracks. 
As eHealth mail communication becomes more widespread, secured interactions between patients and physicians, such as follow-up inquiries, receiving data from home monitoring and accordingly adjustment of medication, will be facilitated. eHealth mail may also promote communication between providers i.e. between the primary care physician and a specialist. Speciality consultations could include an e-mail message with an encrypted attachment of a patient's test results, a secured link to the patient's archived digital radiograph or a digital photo of a skin lesion.
In a milestone article Slack presents the incomplete but encouraging underlying evidence for patient-physician communicant. The article emphasizes how eHealth communication can help physicians better incorporate into clinical practice one of the most underused resources in medicine – the patient – whose help is greatly enhanced through this new technology (3).
Major potential barriers and concerns regarding eHealth communication implementation include confidentiality and security issues, concerns regarding a deteriorating effect this remote communication module might have on patient-physician relationship, potential overloading of the physician with unnecessary electronic mail (4), and legal-malpractice questions that should be further explicitly addressed and defined as this new communication channel may expose both patients and physicians to vagueness not recognized during traditional patient-physician encounter.
Though general email communication is wildly used, eHealth mail is still under-used as was apparent in a 2002 survey, showing that only 6% of respondents reported using e-mail to contact a physician or other health care professional (5).
The American Medical Association (AMA) has released guidelines for physicians using e-mail in an attempt to standardize electronic communication. These suggestions advise establishing timely responses, discouraging e-mail communication for insistent matters, explaining electronic mail procedures to patients, and making the patients informed that e-mails can be printed or copied and inserted into standard patient records (6). Urged on by the AMA and the American College of Physicians, insurers and health plans are exploring ways of paying physicians for using email (7).
As with other healthcare IT systems, eHealth communication applications prosperity depends on an appropriate methodological and usability characterization, designing it to fit both patients needs and physicians workflow.
Clinician-Patient Electronic Messaging
More and more patients expect to be able to communicate with their doctor via email. Messaging via secure websites makes it easier to accommodate relatively sensitive clinical information this way, and has the added benefit of creating documentation in the health record- a written record in the patient’s words. Electronic messaging is asynchronous so that it can be fit into a busy clinicians day, and patients appreciate being able to spend more time formulating their questions and concerns. Electronic messaging allows links to reliable web based informational resources that can also be a source of efficiency and patient centered care.
Clinicians worry about endless, time consuming emails, but experience has shown that this is seldom an issue. In fact, email may allow physicians to answer questions with less time compared to telephone calls.
Guidelines for using e-mail are available. The American Medical Association has articulated appropriate policies, confidentiality and ethical issues in a succinct document referenced below.
Reimbursement strategies for electronic messaging remain a challenge. Some payors compensate for 0074T coding, standards and criteria are defined, but many providers remain uncomfortable distinguishing between informational messaging and billable eVisits. Electronic messaging likely provides an opportunity for more efficient and continuous provision of health care, however.
Tips for effective patient e-mails
- Assess the emotional impact of the message. An emotional topic may be better communicated in person or by phone. However, patients may also prefer the emotional distance that e-mail affords.
- Match formality with what has been established during encounters. E-mail that is more or less formal than the established relationship is disconcerting.
- "Dear" is more formal and generally acceptable.
- "Hi" is less formal.
- "Greetings" is acceptable.
- "Sincerely" is formal and may sound computer generated.
- "Regards" and "best wishes" are currently well accepted.
- Make emails easily readable: use bullets or lists, short sentences, punctuation, and white space. Do not overestimate health literacy issues - the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions (Institute of Medicine).  
As implementation of electronic health records (EHR) has become more commonplace in not only large healthcare organizations, but also smaller private practices, emails between patients and providers have become an integral part of physician practice. What was formerly called email has now become a different entity of its own in healthcare. To avoid confusion with personal email accounts that are provided by such companies as Google or Yahoo, the nomenclature for emails in healthcare has begun to change. A simple google search yielded such terms as "secure messaging", "HIPAA compliant email," "secure electronic messaging" or "secure email."
Secure Messaging and Meaningful Use
The Meaningful Use (MU) program is part of the federal HITECH Act of 2009 to provide incentive payments to health care providers to use Electronic Health Records (EHR) in a "meaningful" way, i.e in a way that improves patient care. The Centers for Medicare and Medicaid Services (CMS) has established measures for eligible professionals (EP) to qualify to become a Certified EHR Technology (CEHRT) to receive these payments and penalties.
In Stage 2 of MU Core Measures, secure electronic messaging was originally measure 17 of 17, which required eligible professionals (EP) to "use secure electronic messaging to communicate with patients on relevant health information." To meet the measure, "a secure message [must be] sent using the electronic messaging function of CEHRT by more than 5 percent of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period." 
These have been modified for 2015 to 2017.
"For an EHR reporting period in 2015, the capability for patients to send and receive a secure electronic message with the EP was fully enabled during the EHR reporting period.
For an EHR reporting period in 2016, for at least 1 patient seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient‐authorized representative), or in response to a secure message sent by the patient (or the patient‐ authorized representative) during the EHR reporting period.
For an EHR reporting period in 2017, for more than 5 percent of unique patients seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative) during the EHR reporting period." 
Impact of secure messaging on clinical workflow
For practices with EHR, patients have begun to utilize secure messaging more frequently to communicate with their providers. While many physicians may have hoped that using this technology would reduce the number of office visits as in early studies,  more recent studies demonstrate otherwise.
In a JAMA article in 2012, a retrospective cohort study done at Kaiser Permanente Colorado measured rates of office visits, telephone encounters, after-hours clinic visits, emergency department encounters and hospitalizations between members with and without online access before and after a patient online access system, called MyHealthManager (MHM) was implemented.  The results "found a significant increase in the per-member rates of office visits (0.7 per member per year; 95% CI, 0.6-0.7; p<.001) and telephone encounters (0.3 per member per year; 95% CI, 0.2-0.3; p<.001). There was also a significant increase in per-1000-member rates of after-hours clinic visits (18.7 per 1000 members per year; 95% CI, 12.8-24.3; p<.001) emergency department encounters (11.2 per 1000 members per year; 95% CI, 2.6-19.7; p=0.1) and hospitalizations (19.9 per 1000 members per year; 95% CI, 14.6-25.3; p<.001) for MHM users vs. nonusers."  However, those patients with chronic illnesses showed more variability. 
The impact of patients utilizing this type of communication with their providers is great. According to the study, "in a health system with 100,000 adult members with online access, if the rate of office visits increases by 0.5 visits per member per year, concomitant with an increase in telephone encounters by 0.3 member per year, over the course of a year, clinicians and the health system would need to provide 50,000 more clinic visits and respond to 30,000 more telephone calls…for a small group practice, a primary care physician with 1000 adult patients who have access would need to provide for almost 10 more clinic visits per week and over 5.5 more telephone calls per week." 
In another study in the Annals of Family Medicine, published in 2014, secure messaging and telephone encounters were associated with increased utilization of office visits for diabetics.  In their study, patient-level regression analyses showed, "that a 10% increase in secure message threads was associated with a 1.25% increase in office visits (95% CI, 1.21% -1.29%), and that a 10% increase in telephone encounters was associated with a 2.74% increase in office visits (95% CI, 2.70%-2.77%). 
In another article, a retrospective cohort study of 2,357 primary care patients found that while secure messages did not increase the number of office visits, it did not change them.  "Subgroup analysis also showed no significant change in visit frequency for patients with higher message use or for those who had used the messaging feature longer." 
The Final Verdict
As of 2016, it seems that e-mail, email, secure messaging or whatever you would like to call it is here to stay. Patients appear to be trending to use technology for healthcare needs and physicians must come to grips that the desktop medicine is part of daily practice. The verdict is still out as to whether secure messaging can be substituted for office visits, as the studies are mixed, and the EHR is still in its infancy. However, despite technology, the human interaction between physician and patient is still needed.
- Rosen P. Patient-Physican E-mail: An Opportunity to Transform Pediatric health Care Delivery. Pediatrics. 2007;120:701-706. http://www.ncbi.nlm.nih.gov/pubmed/17908755
- SUUHSC Readability
- SMOG: Simple Measure of Gobbledygook. Wikipedia. http://en.wikipedia.org/wiki/SMOG
- Uncoordinated Care: A Survey of Physician and Patient Experience. http://www.chcf.org/documents/hospitals/UncoordinatedCareSnapshot07.pdf Last accessed May 11, 2008.
- Gartner. 2006 Survey of Web Portal Uses and Trends in U.S. Care Delivery Organizations. Access requires subscription.
- Slack WV.A 67-year-old man who e-mails his physician. JAMA. 2004;292:2255-2261.
- Moyer CA, Stern DT, Katz SJ, et al. "We got mail". Am J Manag Care. 1999;5:1513–1522.
- Baker L, Wagner T, Singer S, et al. Use of the Internet and for health care information. JAMA 2003;289:2400–2406.
- Bovi, AM., and CEJA. Ethical Guidelines for Use of Electronic Mail Between Patients and Physicians. The American Journal of Bioethics 2003.3(3): W43-W47.
- Gottlieb S. US doctors want to be paid for email communication with patients. BMJ 2004;328;1155.
- AMA (YPS) Guidelines for Physician-Patient Electronic Communications 
- Delbanco T. Electrons in flight--e-mail between doctors and patients. N Engl J Med. 2004 Apr 22;350(17):1705-7.
- Komives EM. Clinician-patient E-mail communication: challenges for reimbursement. N C Med J. 2005 May-Jun;66(3):238-40
References for 2016 Update
1. Eligible Professional Meaningful Use Core Measures, Measure 17 of 17. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_17_UseSecureElectronicMessaging.pdf Stage 2. October 2012 . Web
2. EHR Incentive Programs: 2015 through 2017 (Modified Stage 2) Overview. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2015_EHR2015_2017.pdf. Web.
3. Zhou, YY, et al. "Patient Access To An Electronic Health Record With Secure Messaging: Impact On Primary Care Utilization." American Journal Of Managed Care 13.7 (2007): 418-424 7p. CINAHL Plus with Full Text. Web. 22 Apr. 2016.
4. Liss, David T., et al. "Changes In Office Visit Use Associated With Electronic Messaging And Telephone Encounters Among Patients With Diabetes In The PCMH." Annals Of Family Medicine 12.4 (2014): 338-343. Academic Search Premier. Web.
5. Palen, Ted E., et al. "Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services." The Journal of the American Medical Association 308.19 (2012): 2012-2019. Web.
6. "Online Patient Interactions Do Not Affect In-Person Physician Visit Frequency." PT In Motion 6.6 (2014): 34. Consumer Health Complete - EBSCOhost. Web.
Addendum submitted by Gina M. Adair, M.D.