In a shocking development, researchers found that Patient-Doctor E-mail Could Cut Income for Physician Practices.

Patients who consult with their physicians via e-mail are less likely to visit their physician and less likely to call their doctor's office, according to data from the Kaiser Permanente Center for Health Research, the Portland Business Journal reports.

Kaiser found a decline of between 7% and 10% in primary care office visits for patients who e-mail their physicians and a 14% decrease in patient phone calls to doctors' offices.

The reduced number of office visits could help save money for employers and insurers, although it also could be financially harmful for medical practices that rely on patient visits for income from insurance reimbursements, the Journal reports.

You have to understand that I am a very tech-savvy physician. We have been on EMR for over 10 years. I am at home today, but just spent an hour logged in at work answering questions and finishing documentation. I give talks around the country about the adoption of technology in medical practice and have personally succeeded where many have failed: increasing income while improving quality using an EMR in a small-office setting. Yet we do not use e-mail with our patients.

It seems appalling to outsiders at the slow adoption of technology by physicians. Patients desire to have communication with their doctors via email. Communication via email improves satisfaction and saves money. But overall, the adoption of email by physicians to communicate with patients is low. As documented in the Journal of Medical Internet Research (emphasis mine):

Results: The 4203 physicians completed the questionnaire (a 28.2% participation rate). Of these, 689 (16.6%) had personally used email to communicate with patients. Only 120 (2.9%) used email with patients frequently. In univariate analysis, email use correlated with physician age (decreased use: age > 61; P = .014), race (decreased use: Asian background; P < .001), medical training (increased use: family medicine, P = .001; or surgical specialty, P = .007; but not internal medicine, P = .112), practice size (> 50 physicians, P < .001), and geographic location (urban 17.2% vs. rural, 7.9%; P < .001). Multivariate modeling showed that only practice size greater than 50 (OR = 1.94; 95% CI = 1.01-3.79) and Asian-American race (OR = 0.26; 95% CI = 0.14-0.49) were related to email use with patients. Remarkably, only 46 physicians (6.7%) adhered to at least half of the 13 selected guidelines for email communication.
Conclusions: This large survey of physicians, practicing in ambulatory settings, shows only modest advances in the adoption of email communication, and little adherence to recognized guidelines for email correspondence. Further efforts are required to educate both patients and physicians on the advantages and limitations of email communication, and to remove fiscal and legal barriers to its adoption.

The reason for this is obvious: the payment system penalizes good care. Patients want access outside of the office and want their physicians to spend time with them when they do come in. How are doctors rewarded for meeting these desires of our patients? Less pay. There will never be widespread adoption of technology when adoption of that technology harms those involved. Not even by physicians like me, who actually like the technology and value patient opinion.

Margins are already very tight. Doctors are not much use to their patients if they have to close their offices.

There are ways around this problem, such as having physicians charge for e-visits or charge a global fee for access via e-mail. But Medicare won't allow physicians to charge above and beyond what they pay for, so to implement this a physician needs to either exclude Medicare patients, or stop seeing them altogether.

The main issue in this case is not physicians' slowness in accepting technology, nor is it simple greed. For there to be real change in this area, there must be a change in the way physicians are reimbursed. Until that happens, expect the low adoptions rate to persist.

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