1. Volume 26 Number 2, Winter 2012 | Building Community, Providing Voice, Supporting Innovation 92
Pediatric Perspectives
Pediatric perspectives
Elizabeth A. Rider, MSW, MD, Editor
Pediatric Provider Attitudes Toward Elec-
tronic Mail Communication with Patients
and Families
Elizabeth Cvercko,
Jennifer G. Christner, MD, Jocelyn H. Schiller, MD
Communication between providers and patients proves an essen-
tial element to the fluidity of the medical care system. The role
of advancing technologies in our society, particularly electronic mail
(e-mail) communication, has greatly grown in popularity 1-4
. Recent
studies report 71-74% of providers use e-mail with their patients
5-7
. Seventy-four percent of parents expressed interest in e-mailing
their child’s provider and 80-84% of parents felt providers should e-
mail with patients 8-10
. Numerous studies confirm the importance of
strong patient-provider communication in healthcare outcomes 11-13
.
Research also shows that e-mail communication between providers
and their patients facilitates the building of relationships, as well as
increased patient satisfaction and quality of care 1,7
. Providers feel
that using e-mail as a form of communication between themselves
and the parents of their patients enhances the relationship by provid-
ing convenience and better communication 7
. Previous reports sug-
gest that providers are satisfied with the time saving aspect of e-mail
communication, as well as the advantage of self-documentation, a
way to remove doubt about the information conveyed between the
provider and the patient 14-15
.
With this mode of communication becoming more prominent, it is
important to understand benefits and barriers to e-mail communica-
tion with patients. Our qualitative study explores the perspectives
of academic pediatric providers on e-mail communication between
providers and parents of their patients.
Methods
In this study, we focused on academic pediatric providers, solicit-
ing opinions of individual providers’ use of e-mail with parents of
their patients, their personal e-mail preferences when communicat-
ing with families, and their attitudes toward electronic communica-
tion with patients. During the fall of 2010, two focus groups met for
our study. One group consisted of four providers while the second
consisted of seven. The focus groups included pediatric subspecial-
ists, general pediatricians and pediatric psychologists, whom were
recruited by an e-mail to pediatric faculty employed at the University
of Michigan Medical School.
During the focus groups we asked the providers about how and why
they use e-mail as a form of communication with the parents of their
patients using a semi-structured interview protocol. The focus group
discussions were recorded, then transcribed by a student research
assistant. Transcripts were read by two investigators (EC and JC). In-
dependent themes were reached by the investigators, who then dis-
cussed these themes in order to reach a consensus of major themes
from the focus groups.
Results
Of the eleven participant providers in our study, 64% were female and
64% used e-mail with their own healthcare providers. Twenty-seven
percent were 25-34 years old, 36% were 35-44 years old, 18% were
45-54 years old and 18% were ≥ 55 years old. Seventy-three percent
were white and 27% were Asian-American. Thirty-six percent of the
providers practiced general pediatrics, 18% specialized in develop-
mental pediatrics, 9% in child neurology and 36% in pediatric psychol-
ogy. Each focus group lasted from sixty to ninety minutes.
Qualitative Results – Focus Group Themes
The investigators used qualitative analysis in order to determine four
major themes in the discussions with the providers. These themes
included building the relationship, convenience, interpretation of
tone, and guideline for use of e-mail as a form of communication.
Transcript excerpts of the participants’ comments are included to
capture their voice.
Building the Relationship
Many of the providers embraced e-mail as a form of communica-
tion that would build the relationships between themselves and the
parents of their patients. One provider said, “When you give them
[patients] the e-mail … it is kind of like giving something personal of
yourself to them.”
Providers also mentioned that e-mail seemed a convenient tool for
communicating with patients of certain age groups. One provider
commented on how e-mail worked well with teenage patients: “I
work a lot with teenagers, and I have some teenagers who will e-mail
me saying ‘I want to talk to you about something without my mom in
the room’ … that’s a nice way for teenagers to set the stage if they
want to talk to me about something.”
All providers agreed that e-mail is a way to build a patient-provider
relationship. They felt it offered another outlet for communication
which was recognized as being optimal for the patient, enhancing
the relationship between providers and patients and leading to bet-
ter care.
Convenience
Providers often found e-mail to be a convenient way to communicate
with patients. For example, providers who routinely asked patients
to record symptom logs found e-mail a very convenient tool to relay
this type of information. As one provider stated, “Patients will re-
turn pain diaries, sleep logs, food diaries … via e-mail so that I can
look at it so that when they come to see me then we can have a plan
and make good use of that time.”
On the other hand, providers expressed concern over the steps it
would take to include the exchange of information in the medical re-
cords, deeming it an inconvenient form of communication. One pro-
vider said, “If I am answering an e-mail, 90% of the time [it] needs to
go into the patient’s chart … so now we’re introducing another step.”
Another aspect of convenience discussed was how questions from
parents of patients that turned into lengthy e-mails with detailed
responses. Some providers stated that they just didn’t have enough
time to respond with such answers. They also stated that this kind
of exchange of information could prove confusing because of the nu-
merous e-mailed exchanged, and that a person-to-person conversa-
tion would be much more convenient and clear than an e-mail. One
provider said, “You could reply with your e-mail [to the patient] say-
ing ‘I don’t recommend it,’ but then you’re going to get an e-mail
back [from the patient]: ‘Why not? What’s your experience been?’
And before you know it you’ve got a four-way e-mail going.”

2. 93 Building Community, Providing Voice, Supporting Innovation | Medical Encounter
Cvercko, E., Christner, J., Schiller, J.
Discussion
With this study, we sought to elicit opinions from academic pediatric
providers on e-mail communication between providers and parents
of patients. We found that overall e-mail communication has infil-
trated the practices of the majority of the academic pediatricians
who participated in our study. Our participants reported improved
relationships with patients and families, especially for teenage pa-
tients, which, in turn, assist in improving patient care. This finding
aligns with prior research demonstrating that e-mail leads to bet-
ter communication between providers and patients 16
. Providers did
note, however, that e-mail communication could be misinterpreted,
which may cause deterioration in the patient-provider relationship.
Further research should be done to measure the overall impact of e-
mail communication on patient-provider relationships and healthcare
outcomes.
Providers were concerned that parents might e-mail with time-sensi-
tive patient information. Although the e-mail guidelines provided by
the American Medical Association (AMA) in 2002 recommended that
providers give patients parameters for the types of issues that are
appropriate for e-mail, the concern by our participants suggests that
the AMA suggestions have not yet been implemented in all clinical
practices that choose to utilize e-mail 16
. The use of guidelines may
also improve the length of email responses by establishing when an
e-mail conversation should be converted to a verbal interchange.
Differences between two groups of providers proved a unique find-
ing in this study. Primary care providers with busy clinical schedules
were not able to respond to the number of patient and parent e-mails
in a timely manner. Subspecialty providers with lighter clinical loads
found e-mail helpful in communicating with patients and parents.
We hypothesize that these findings are due to the differences in pa-
tient care volume. Reimbursement and protected administrative
time to respond to patient e-mail need to be considered.
Although some providers reported that e-mail added convenience,
other providers noted that e-mail increased the steps needed to doc-
ument medical care. Improvements in computer systems and office
infrastructure may improve this barrier.
A limitation of this study is the small sample size from a single in-
stitution. However, within our focus groups, we encountered a di-
verse collection of providers. Each brought different perspectives
and themes to our discussion. Future studies should include greater
numbers of providers from multiple types of practices to confirm our
findings.
Conclusion
Overall, providers expressed that e-mail had a positive influence on
the relationships with patients and parents. Providers with busy clin-
ical schedules, however, reported a lack of time to respond to patient
e-mails. Guidelines and infrastructure need to be in place to enable
providers to effectively respond to e-mail. Further studies need to
explore the actual effect of e-mail tone on the patient-provider re-
lationship.
Interpretation of Tone
Providers expressed concern over the tone of voice portrayed through
e-mail communication. For example, one provider discussed how the
tone could give the wrong message, “We can so easily insult people
or be a little short with people through e-mail. You know, we can all
think of instances where we really put someone off by how we re-
plied to an e-mail inadvertently, where we didn’t intend that at all.”
Another provider stated that parents of their patients could misinter-
pret the meaning behind their message and the relationship between
the providers and the parent could deteriorate. One provider said,
“I think that the parent might be defensive saying ‘I’m not being
heard,’ even though there’s a lot of information in [the provider’s
e-mail].”
Guidelines for Use
Many of the providers who participated in our study commented on
the importance of setting guidelines and boundaries for e-mail com-
munication with their patients or parents of patients. Providers dis-
cussed how e-mail was viewed by some patients as a form of urgent
communication, and it proved inconvenient to themselves as well
as potentially dangerous to the patients if the provider could not
respond in a timely manner. A provider stated, “There’s always that
instance where you’re away at a meeting or on vacation and some-
one’s e-mailed you something sort of critical … and you weren’t there
[to respond].”
Providers in our focus group discussed how they offered e-mail as a
form of communication in their practices. For example, some provid-
ers who participated in our study provided patients with their e-mail
address right away. Some of the providers did not advertise their
e-mail address at all. The providers who worked in primary care
settings and used e-mail quite frequently stated that many parents
did not respect boundaries of e-mail communication or understand
appropriate e-mail content. The topics and lengths of e-mails esca-
lated into subjects inappropriate for the providers to respond over
e-mail communication.
Many expressed that there was a right and a wrong time for the use
of e-mail, and how important it is to create guidelines for the patient
base in order to ensure the best route of communication with pa-
tients. For example, one provider discussed that she offered e-mail
as an option for communication with her patients, but right away
gave warnings of her expected response time and offered guidelines
to patients regarding using e-mail with her as a form of communica-
tion. “For every patient that I see I actually offer the e-mail option
… I always give the caveat that e-mail usually takes me a little bit
longer to get back, so a few days, so if it’s more urgent, definitely
call, but I always offer that [e-mail option].”
Differences Between Faculty Groups
We found the overall responses from the providers in our study fell
mainly into two categories: primary care versus subspecialty. Pro-
viders who worked in a primary care setting generally provided a
negative response to e-mail communication because of the time com-
mitment and unnecessary steps. They felt that responding to numer-
ous e-mails in a day proved a great inconvenience and was often
impossible to respond in a timely manner. Providers who worked as
subspecialists, many of whom in our sample had less clinical responsi-
bilities and a subsequent smaller patient base, responded positively.
The subspecialists felt that e-mail communication helped build the
relationship between themselves and the parents of their patients
and even created more convenience when it came to preparing for
appointments.