Why Accepting Patient Email is a Practical Requirement of the Affordable Care Act

The following is a guest post by Zachary Landman, M.D., Chief Medical Officer for DoctorBase.
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With the infusion of 30 million patients into the U.S. healthcare system in the coming years, the physician shortage is only going to worsen. In Massachusetts, which has had a similar healthcare legislation enacted since 2006, improvements in healthcare coverage and access are highly associated with physician shortages. Prior to the implementation of the health law in Massachusetts, internal medicine and family practice physicians were in deemed to be in “adequate” supply. Almost immediately following the legislation and in nearly every year since, however, the specialties have listed as “critical.”  While the percent of covered patients in the system has reached upwards of 95%, the result has been that physicians are increasingly difficult to visit. Appointment wait times have soared into weeks and months for some specialties and there has been frustration from both patients and providers regarding access.
MMA workforce 2006 and on
An even direr scenario is expected to play out on a national scale when 55 million people currently without insurance enter the healthcare market through subsidized exchanges. Economists predict that the current shortage of physicians will balloon to 63,000 by 2015 and escalate to 130,600 by 2025, due to both increasing demand and dwindling supply. To add salt the wound, a 2012 Physicians Foundation survey demonstrated that nearly half of the 830,000 doctors in the U.S. are over 50 meaning that as the number of patients swell, the supply of physicians will conversely retract.

Clearly, the way healthcare is provided will need to fundamentally change in order to accommodate the three main tenants of the Patient Protection and Affordable Care Act: Access, Quality, and Cost. One potential way is to simply force physicians and healthcare providers to see more patients in the current set of time or work longer or more frequently to maintain their level of reimbursement. Physician time, however, especially for chronically ill and complex patients has become a relatively “inelastic product.”

Physicians already experience significant rates of burnout, are feeling overworked, and have increased the frequency of patient visits to between and 6 and 9 minutes per encounter. Some studies suggest that trying to reduce this amount of time further may actually cause an increase in costs due to inadequate care, counseling, and increased frequency of complications. I would therefore argue that we have reached a point at which physicians cannot increase the volume and frequency of patient care without a fundamental alteration to the paradigm of healthcare.

Secure email may just be the answer. Securely messaging patients can provide a way to fundamentally alter the type and scope of care provided remotely leading to a maintenance or even reduction in the amount of patient care conducted in the office. The fundamental “if” in this scenario, however, is that it must save physician time. For example, physicians have known the value of hand hygiene in patient care for nearly two centuries, but only recently has widespread adoption been shown in an inpatient setting. What led to the main change? Time.  It takes considerable time to cleanse hands thoroughly between each visit. Only when the practice became a time-neutral or time saving event were physicians keen to alter practice behavior. With the inclusion of quick, visible, and easy to use dispensers outside each patient room, these two principles finally coincided.

It’s the same with email. Many physicians worry that by accepting patient messages, their already inelastic time will continually be stretched, forcing them to work longer and harder for a non-reimbursed activity.  After studying more than 11,000 physicians over three years, I have found that the effective use of secure messaging saves physicians on average 45 minutes per day.

Three hours and forty-five minutes per week. That’s a lot of time. And here’s where it comes from.

#1 – Triage. Physician messages should be directed to a practice manager or physician extender who triages the messages and forwards to the appropriate individual. In our case, we found that nearly two-thirds of “physician” messages could actually be handled by office staff. These messages were typically related to hours, availability, insurance coverage, consultant phone numbers, or other back office functions. Our surgeons found that by including a nurse practitioner or physician assistant could also further reduce the number of “MD-level” messages.

For example, minor concerns regarding wound or incision appearance, follow-up timing, suture removal, or questions from visiting nurses were all routinely and commonly handled by the midlevel provider. The exact nature of each question was handled in accordance with physician comfort and expectations. Ultimately, the number and quality of the messages that were directed to physicians were important, timely, and appropriate which led to fewer ED visits, sameday appointments, and phone calls.

#2 – Mobile. Physicians who are able to read, review, and send messages from their mobile device were able to find a considerable amount of “lost” time in their day. Physicians are constantly on-the-move: between patients, rounding, to the hospital and back, to lunch and back, on the elevator, etc. We found that these “micro-minutes” in each day added considerable effectiveness to mobile messaging. As discussed in #1, physician messages were already screened to be important and relevant and so a timely response is indicated. Physicians were able to answer these questions on-the-fly, leading to further confidence in the system on behalf of the patients and fewer voicemails or messages to return at the end of each day.

#3 – Voicemail. Voice messages are the bane of nearly every provider’s life. They are difficult to understand, slow, and take considerable time to review, record, and answer. Through points #1 and #2, the volume and frequency of voicemails decline considerably. The top competitor to patient portals and secure messaging is the phone. It’s universally understood, easy to use, and an immediate response is obtained. Only when patients have an easy to use portal that they can easily access anywhere (and from any device), send a secure message with confidence that it will be reviewed by the provider in a timely manner, and rewarded with a response will patients choose a new system. That’s exactly what our experience has been and there’s absolutely no reason that this cannot be replicated on a national scale.

Whether secure patient email (and ultimately our healthcare legislation) is a failure or a success relates to the patient and provider experiences and our ability to create a harmonious interplay of accessibility, ease of use, and time.

Zachary Landman, M.D. is the Chief Medical Officer for DoctorBase, a San Francisco mobile health technology company considered to be the leader in mobile cloud-based health messaging services that serves more than ten thousand providers and nearly five million patients. Landman is a former resident surgeon at Harvard Orthopaedics and graduate of University California San Francisco School of Medicine. During his career at the intersection of healthcare, technology, and industry, he has developed interactive online musculoskeletal anatomy modules for medical students, created industry sponsored resident journal clubs, and published numerous peer reviewed articles on imaging and outcomes in spine and orthopaedic surgery. Currently, he is leading the development of DoctorBase’s pioneering patient engagement and automated messaging suite, BlueData.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • I totally agree – I think, though, that there needs to be a way for doctors to get paid for that email time if we want them to buy in.

  • Geri,
    It certainly would make the case for doctors to email patients much easier if they were paid to do it. I’ve seen a few models for this and you’re right that many won’t do it until they get paid for it. Although, there’s a case to be made that email saves doctors time. If more doctors see this time savings, then they’ll tell their colleagues and more doctors will start doing it.

  • In San Francisco anyway, we are seeing doctors that accept email blow past the offices who stubbornly refuse to on Yelp, Google etc. So the new norm/trend seems to be that accepting email from patients is the value add in hyper-competitive markets. Having said that – attorneys get paid for phone and email time. Fair is fair – no one works for free.

  • As a patient I don’t think I would be willing to pay for a quick question about billing, prescription or appointments. But if a secure message saved me a trip to the doctors office, yeah I would pay for it. Zach, can you shed some more light on why physician supply is going to contract? I get that a lot doctors are going to retire soon. Why would we not see these retiring doctors be replaced by younger doctors at a comparable rate?

  • Docs are busy, they do not have time for emails from patients… my first thought…. upon reading this article, my mind has changed… some great points, ie screening the emails first by office staff, MOBILE access (huge for patients too!), and yes$$$ for doctors too.

    Are there any platforms or EMRs out there that allow docs to get paid for email?

  • Re: Triage… doesn’t that happen already, for traditional dr office visits? It’s not like the dr is just sitting in the lobby and treating every patient as they happen to come in with whatever they have.

    It also seems like emailing your dr would save the patient’s time more than the dr’s, in most cases.

  • I can see how mobile communication could save valuable time. As a patient, I don’t always know which of my questions need a full consultation with my doctor and which questions can be answered by the office staff.
    As a student, making an appointment during business hours can be very difficult. I would pay to have a question answered in between classes.

  • Secure messaging is the important factor here. Just shooting your doc an email from your hotmail account won’t cover it. When looking for a physician, check their website to see if they have some kind of patient portal that offers secure email messaging.
    These messages are generally reviewed by an office/nurse manager and then routed to the appropriate person. More times than not, the question is answered by office staff. When the issue is directed to the physician, it is similar to how phone call messages are handled, only instead of calling the patient back, the physician replies via the secure email messaging system.

  • Susan,
    Actually, if the patient shoots the doctor an email from their hotmail account, it’s fine: http://www.hhs.gov/ocr/privacy/hipaa/faq/health_information_technology/570.html The patient can choose to send it that way if they want to do it that way. The doctor on the other hand can’t just shoot a patient an email with PHI to the patient’s hotmail account without the patient acknowledging that it’s ok.

    With that said, there are some secure ways to send the message like you said that are better than just a straight email.

  • Of course John. The patient is free to send the physician an email with any type of account. My experience has been that physicians prefer having secured messaging to avoid any type of HIPAA issue that could occur. With that in mind, they may not accept an email coming from a Hotmail or other account. Thanks for the link!

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