Patients today tweet, text, chat, and email more often than they talk on the telephone, and many want to communicate electronically with their doctor's office as well.^1,2 However, many medical practices are not eager to join the electronic age.³ Our large multispecialty group was no exception. We assumed that our patient panel, almost 70 percent Medicaid with many having low levels of health literacy, would be disinterested or unable to access electronic communication. We also assumed that secure messaging would add a significant burden to our already overworked staff and increase our time spent answering messages.

We couldn't have been more wrong. Now, up to 1,000 electronic messages per physician pass through our electronic health record's (EHR's) secure messaging portal each year. We use the system to handle a wide variety of tasks, from managing refill requests to communicating lab results, and we have found that the benefits outweigh the challenges. Adopting secure messaging not only has helped us provide more satisfying, efficient, and effective patient care with no more hassle, but it also has helped us meet the National Committee for Quality Assurance's requirements for patient-centered medical home certification, which has helped us obtain higher reimbursements from certain payers.

What follows are the myths and facts of secure messaging, as well as a few pitfalls to avoid.

Three myths

Myth #1: Patients who are poor, elderly, or living in rural areas won't have the desire or ability to use secure messaging. Because of this false assumption, we initially marketed the service only to our commercially insured patients. Many signed up and indicated we had met their expectations, but they seemed less excited about the technology than we had assumed they would be. However, when we offered the service to our Medicaid population, we found them to be the most enthusiastic about the possibility of improved access to their providers. In addition, in keeping with existing studies,⁴ we found that our geriatric patients or their caregivers were just as receptive to this form of physician-patient communication as our general patient population. Overall, almost 30 percent of the patients we recruited registered their email addresses online and began to communicate electronically with us. In my own practice, more than 50 percent signed up. While many rural areas still lack adequate Internet access, more are gaining high-speed Internet access every day, and these patients are waiting anxiously for it.

Myth #2: Leaving brochures in the waiting room or including them in lab letters will get patients to sign up. Our practice tried this. We placed full-color leaflets in the waiting rooms and at the reception desks – and discovered them sitting untouched at the end of the day. We also mailed leaflets with our lab letters and billing statements, and patients apparently treated them as junk mail and ignored them. It was a waste of time and postage. Fewer than 100 people signed up after we sent out thousands of leaflets. Ultimately, we found that recruiting patients to participate meaningfully in secure messaging required the physician to tell them about the service and why it is important.

Our physician spiel went something like this (while handing the patient a leaflet): “This is one other way you can contact our office if you'd like to message us instead of waiting on hold. In addition, I can send you your lab results through this secure system and you can print them, save them, or take them to your other providers. If you have a question about your results, you can send me a message.”

This explanation added less than 15 seconds to our office visits, and patients seemed to like the idea that they could message their doctor as they do their friends. One year after adopting this approach, our practice's secure messaging membership had skyrocketed, and the message volume had more than doubled.

Myth #3: Messaging patients adds “one more thing” to my day. Before groaning that an increase in electronic messages means more work, consider this: As the volume of secure messages increased in our practice, we experienced a proportional decrease in phone call volume. In addition, we discovered the advantage of being able to respond quickly to messages after hours or during lunch without having to worry about whether patients would actually be at the phone number they had given. Physicians inherited no added burden because our workflow already required that they review phone messages. In fact, electronic messages were more efficient because they allowed us to eliminate the step of handing the phone message back to the nurse to call the patient. We were able to relieve our nursing staff of some of the work of answering phone calls so they had more time to spend with patients in the office. The only time patients messaged and also called was when we hadn't been swift enough in our reply. Because we ask patients to allow 24 to 48 hours for a reply to their messages, this is an uncommon event.

Three facts

Fact #1: Secure messaging saves money. Postage isn't getting any less expensive. Creating a lab letter and sending it electronically to the patient requires just two clicks in our system – far less time and effort than routing the same letter to a staff member for printing and mailing. About 90 percent of my outgoing messages are attributed to lab notifications, and I sent more than 700 messages last year practicing part-time. I sent fewer than 200 lab letters in the mail. The savings were realized both in supply costs and in the time it would have required an hourly staff member to print, fold, address, and stamp envelopes.

Fact #2: Secure messaging helps me document appropriate care and avoid lawsuits. When patients leave secure messages, their actual words are recorded in the chart because our messaging system is connected to our EHR. If I don't understand what they need, I can message them for clarification, and the entire conversation is recorded. Patients' actual words are gold, whether in an electronic message or in the office setting. Not having to translate what the nurse heard and wrote down reduces the chance that I will misunderstand the urgency of the phone message and risk harm to my patient or liability to my practice. By not limiting the word count in the message, and by eliminating the time constraints we all feel when leaving a message by phone, I can offer patients the luxury of being as complete as possible when outlining their concerns. In addition, I have found that patients are as conversational in secure messages as we all are in emails. Having little statements in the chart such as “Thank you, you're the best, most caring doctor ever” (from the patient) and “Thanks so much for being such an active partner in your health” (from me) help demonstrate the rapport between us. In addition, when a patient denies having received his or her lab results or the important advice I've sent, I can confirm that they have opened the document. I cannot do that with paper mailings without paying for certified mail delivery, which is not practical.

Fact #3: Secure messaging improves patient care and patient satisfaction. We measure patient satisfaction with nationally validated survey tools every month. We have found that practices that have adopted secure messaging within our family medicine group have higher scores than our other practices on questions related to “ease of communicating with the physician” and “understanding of diagnosis/treatment plan.” These measures are important, particularly in an academic practice where we are all part-time physicians. We also have found that patients' expectations for online communication are different than for phone messaging. In American culture, we are used to having our concerns addressed immediately when we call for service; however, when we email, text, or message someone, we assume that person will reply as soon as he or she is back online. In addition, we found that patients used the electronic messaging technology in ways that improved their quality of care. For example, many downloaded their medical histories to their electronic devices in case of emergency or printed their lab reports for their visits with subspecialists. We found this to be a more reliable way of getting information to consultants than faxing the information, where it is often lost in the paper shuffle on one end or the other.

Three pitfalls

Despite this rosy outlook on messaging, there are dangers ahead when adopting any new system for physician-patient communication. About one year after adoption of secure messaging, we ran into some issues that required us to rethink parts of our workflow and how patients create and access their accounts. By sharing these, I hope to help you prevent the same challenges in your own implementation.

Pitfall #1: Unchecked messages when the physician is on vacation. Many of my patients followed me from private practice and now drive 30 miles out of their way to see me. I value their loyalty and try to do what I can to maintain the open communication I had with them at my old practice. To that end, when offered the choice in our secure messaging system of whether to allow patients to reply directly to my outgoing messages, I always allowed it. Later, I found patients had become accustomed to using old outgoing messages and “replying” with new questions instead of using the “send a message” feature within the system. Our workflow within the EHR caused all “replies” to my outgoing messages to be routed directly to me, whereas new messages would have been routed to a staff member. Normally, this isn't a problem, but I once returned from an “unplugged” vacation to hear of angry patients who had waited one to two weeks for a response to their acute complaint or refill request, and who blamed my office staff for failing to care for them.

After appropriate mea culpas, I reassessed the situation and decided the best solution for us was simply to not offer the “reply” feature going forward. Of course, it took several months for those patients with active outbox messages to stop hitting “reply” and more than a year for me to smooth the feathers of those patients who didn't like the change. An alternative solution would be to establish a coverage system when physicians are away, by either having staff review and triage messages or having a physician partner review them.

Pitfall #2: Patients who use the system for urgent health concerns. Because we allow patients who call with significant acute complaints to be transferred immediately to a triage nurse, some patients expected that they should be able to use the secure messaging system for urgent matters as well. We included the usual disclaimer at the bottom of the message box, warning that emergency concerns should not be left in a message, as well as language asking patients to allow 24 to 48 hours for a reply. We found that despite these efforts, once or twice a week a patient uses the system to report acute concerns. Unfortunately, it is not always possible to extinguish undesirable patient behaviors, so we have had to adapt our workflow. Now, all incoming messages are first routed to the phone room as calls would be. Our phone room staff has been able to reduce the response time for those messages that require more urgent assistance by quickly routing them to the triage nurse for action.

Pitfall #3: Risks to patient privacy. We initially invited patients to use secure messaging by going to our patient portal website and entering their full name, Social Security number, and date of birth. If the data matched what was in our registration system, an account was created. We later realized that any person who possessed a patient's information could create an account and send and receive messages. Well-meaning caregivers of elderly patients and mothers of children who had reached maturity could create accounts without the patient's permission in order to communicate with the physician or view information in the chart, such as current problems, current medications, allergies, and diagnoses for which the patient's account has been billed. While we found no breaches of patient confidentiality (the sole known example was a mother who created an account for her minor daughter), we recognized the inherent risk of our process. To solve this, we changed the way accounts are created. Now, to create an account, patients must possess a unique personal identification number, which they can obtain only in person at the office. This has decreased the number of new accounts created but has improved the security of the process.

If you are considering adopting secure messaging, whether to meet patient-centered medical home standards or to improve office efficiency or patient satisfaction, go ahead and make that leap knowing that the benefits will outweigh the hassles. For those of you in the adoption process, take note of our pitfalls as you forge ahead. And for those of you who have already been down this road, please share your wisdom so we can all learn better ways of meeting our patients' expectations and providing them with the best support possible in their continued efforts toward good health.