Review
The impact of patient–physician web messaging on healthcare service provision

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Abstract

Background

Information technology can support the delivery of healthcare. Patients are eager to make use of such tools as web messaging, yet its deployment has been limited to date. A fear still pervades that the cost associated with a possible increase to physician workloads may outweigh any suggested benefits.

Goal

This paper aims to review the body of research completed in the area of patient–physician web messaging. The findings of this review will then be assessed and synthesised, with the intention of creating an overview of both the benefits and costs of patient–physician online messaging. Areas of particular importance to future research may then be identified.

Results

Demand and support for online communication tools amongst patients is strong, and can increase quality of care due to increased patient–physician communication. Although there would seem to be great potential to increase process efficiency, there would not seem to be sufficient evidence as of yet to suggest that this is the case.

Conclusion

Further quantitative research in particular is required to assess the impact of online communication, with special regard to the effect on overall patient demand and on healthcare process efficiency.

Introduction

It is not at all unusual for people to buy groceries, do their banking and communicate with their lawyer online. Consequently, patients are also very enthusiastic about communicating with their physician electronically [1], [2], [3], [4], [5], while many consider it to be influential to their choice of physician [6] and health plan [7]. Indeed, it has been noted that the term ‘patient’ is slowly being replaced by ‘consumer’ [8], and to more adequately address their ever increasing needs, some healthcare providers (organisations that provide healthcare services) have embraced e-health: the support and delivery of healthcare with information and communication technology. The resulting patient portals have enabled patients to perform a number of functions online, including viewing their personal health record (including test results), renewing prescriptions as well as communicating electronically with their physician and other specialists.

The motivation behind the provision of these services is primarily to improve healthcare delivery [9], which currently suffers from a number of shortcomings. For example, many patients are left frustrated because their needs are not fully met during the course of medical encounters [10], including not receiving as much information as they would like [11], [12]. The wider implications of interview topics may not become apparent to the patient until they have had some time to reflect, at which point the appointment is long terminated [13]. Yet, patients find it difficult to contact their physicians by telephone [4], and physicians themselves are frustrated with playing ‘telephone tag’ [4]. Patients can also be reluctant to discuss sensitive issues, not just in appointments but also by telephone, and are more comfortable doing so online [14], [15], [16].

Despite the great promise of online healthcare solutions, their proliferation has been limited to date. Concerns remain over the type, scope and extent of the resultant impacts of electronic communication. A number of studies have assessed the impact of these tools, although with varying foci, settings, systems and perspectives. As a result, many will remain reluctant to deploy these tools until a more comprehensive understanding of their costs and benefits emerges. The research question is: What is the impact of electronic communication to the efficiency and effectiveness of healthcare service provision? This study aims to address this research question by providing a synthesis of findings based on the research conducted in this area to date, and to then suggest directions for future research.

As healthcare systems in different countries vary; the specific context in which healthcare services are offered must be taken into account when analyzing the challenges and potential benefits of introducing online patient–physician communication. The US has been selected as a nominal setting for this discussion, although the main themes may be relevant to many other countries also.

This paper commences with a description of the methodology used to find relevant articles. This is followed by an examination of online patient communication and the various forms that it can take. Its impact on process effectiveness is then examined. This is then followed by an investigation into the effect of operational efficiency, with particular reference to the effect on communication volumes.

Section snippets

Methodology

Articles for our literature review were gathered by means of an online search of the following databases: Medline, Pubmed and ScienceDirect. Search terms included web messaging, electronic communication, email, e-mail, and online communication. Reference lists of articles uncovered by this search were scanned in order to find other relevant material that was not covered by the parameters of our initial search. Our search was restricted to the body of research conducted in English. The most

Online communication between physician and patient

E-health has been defined in many ways, although we chose to use the following definition for the purposes of our study: the use of emerging information and communication technology to improve healthcare delivery [9]. This encompasses everything from patient-accessible Electronic Health Records (EHRs) to patient–physician online communication to electronic prescribing. Online patient–physician communication is a particularly important aspect of e-health since it serves as both a new

Electronic messaging based online communication

Both synchronous and asynchronous online communication tools have been tested in the healthcare environment. Synchronous online communication in the form of ‘webchat’ was found to alleviate problems associated with shyness, although ultimately is of limited use due its increased time demands compared to face-to-face appointments [17].

The proliferation of asynchronous communication tools such as email for clinical purposes has also been limited to date. Concerns were raised over their

Customer satisfaction

Patients perceive access to online communication to be a factor that would influence their choice of physician [6], while Internet users in particular consider it to be something that would influence their choice of health plan [7]. The implication is that patient demand for access to this type of service is strong, and provided that attempts are not made to restrict access to physicians by telephone or for appointments, there is no reason to suggest that granting them access to an additional

Physician productivity

Physicians who use web messaging in their practices have been shown to achieve a higher level of patient visits per day [20], [21]. This may be due to a resultant increase in process efficiency, which has been suggested anecdotally [20]. For example, web messaging is a self-documenting communication channel, and so does not require the physician to compile a separate log. However, the authors were unable to find a study measuring the processing time per message, telephone call, or appointment.

Potential stakeholder benefits

The potential benefits of online communication that were explicitly mentioned in existing literature have been complemented by our own analysis, the results of which have been broken down by stakeholder, as shown in Table 2. This analysis was conducted with particular reference to the ‘raison d’etre’ of each stakeholder, and so the core motivation of stakeholder has also been included. Some of these benefits are self-evident. Others are not so self-evident yet have not been corroborated, and so

Theoretical implications

The studies reviewed in this paper indicate that differences in patient telephone call and appointment volume between web messagers and control groups are minor. Web messaging does have a positive impact on patient satisfaction, while there is no reason to suggest that it would do anything but improve quality of care. The consequent long-term effect of a closer patient–physician relationship, improved disease management and prevention should be explored in greater detail. Further research is

Conclusion

In this paper we provide a review and analysis of the current body of literature concerning online patient–physician communication, primarily in the form of web messaging. The key themes of this research were explored and summarised in this paper. A particular emphasis was placed on the importance of understanding the possible impact on patient demand from the perspective of demand management. Based on existing research it is too early to make strong conclusions about the impact of these

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