Use of email, cell phone and text message between patients and primary-care physicians: cross-sectional study in a French-speaking part of Switzerland

Electronic communication dominates our current world. More than 3.3 billion e-mail accounts were opened in 2012 and this figure will reach 4.3 billion in 2016; every day 144.8 billion emails are sent in the world [1]. In Switzerland in 2014, more than 91 % house-holds had access to internet and nearly 75 % of the population above the age of fourteen used Internet every day. Similarly, more than half of the world population owns a cell phone [2]. In Europe, several countries have a mobile phone-population ratio higher than one; in Switerland, the ratio was 1.4 in 2014 [3].

Use of electronic communication in healthcare is driven by the idea it can improve accessibility, quality and performance of health service delivery [4]. More than 85 % of physicians use the internet and 55 to 64 % use email to correspond with colleagues and support staff [5]. Ten years ago, 20–25 % of European general practitioners reported using email to communicate with their patients [6]. Increasingly patients are willing to use electronic media to communicate with their physician. It provides them with a feeling of safety and easier access to care. Yet a significant percentage of physicians are reluctant to exchange emails with their patients [7, 8].

The use of cell-phone communication in health care has recently been subject to less studies but its use does not seem to have decreased with the rise of email communication [4, 9]. In a study published in 2011, about half of the physicians offered to communicate with their patients by telephone [10]: it allows them to choose to answer according to specific time slots, disconnect the phone when needed and avoid miscommunication [10‐12]. Text message is commonly used in health care settings. However, a systematic review on the use of text messages in health care indicates that it is used mostly for one-way communication from providers to patients, disease management, administrative processes or preventive care [13].

Most studies that have addressed the use of emails and cell phone communication in health-care settings were conducted in the early 2000’ and mainly in the United States and Israel. Use of email communication in Europe appears to be extremely variable and closely linked to a country’s main health policy (development of ehealth): the percentage of citizens (aged 16–74 years old and internet users) who reported sending or receiving en email form their doctor-nurse or health care organization varied from 18.7 % (France) to 50.7 % (Denmark) [14]. Little is known on the use of such communication tools in Switzerland. The aim of this study was to explore the frequency and type of use of email, cell phone and text message communication by primary-care physicians in a French-speaking part of Switzerland. We were also interested in primary-care physicians’ views about the advantages and disadvantages of using these communication tools. Finally we sought to explore whether physicians established rules for use of email to communicate with patients.

Of 636 questionnaires that were sent, 412 (65 %) were returned. Excluding uncompleted questionnaires (37 refusals and three blanks), 372 (58 %) questionnaires were available for analysis regarding e-mail communication and, because some participants did not respond to questions situated at the back of the questionnaire sheet, 322 (51 %) were available for the analysis in relation to the use of cell phone and text message communication.

Table 1 shows that there was an equal number of male and female participants; most of them were over 49 years old and worked in an urban area. Eighty-seven percent of participants (n = 324) used the computer for billing purposes and 48 % (n = 179) used it to write prescriptions, 44 % (n = 163) to enter patient information in the electronic medical file and to show results to patients.

This study shows that nearly 72 % primary-care physicians in Geneva Switzerland gave their patients access to email communication and 70 % gave their cell phone number to their patients in 2013. Physicians felt that all communication tools helped them build a better relationship with their patients as well as gain time but were associated with the risk of misuse and encroachment on private life. Doctors uncommonly discussed confidentiality issues in relation to email communication with their patients, and more than half of them did not bill such communication.

The rate of physicians offering email communication to their patients is higher than what has been previously reported and naturally follows the constant rise of email use in everyday life [19]. However, primary care physicians still remain cautious in its use and restrict it to a minority of patients [20]. The fact that physicians use email, phone or text message communication for different purposes suggests that these tools respond to different needs. Sophisticated web based health systems providing online communication (called patient portal), as implemented in many U.S. and U.K. healthcare institutions, may therefore not replace phone-based interactions [21‐23]. For example, phone communication is still considered by both physicians and patients as a way to improve care and follow-up and to reduce unnecessary visits to emergency services [4, 10, 11]. Patients also expect physicians to phone to communicate test results–it is thought to improve patient understanding, provide reassurance and increase quality and continuity of care [24, 25].

However, the reported use of email communication for changing appointments suggests that most practices do not have effective incoming email triage processes. Several studies show that appropriate triage of incoming messages by office staff or web-based messaging systems helps manage email flows, improve the efficiency of office communications with patients and increase patient safety and physicians’ acceptance of email communication with patients [26].

The disadvantages of email and phone communication relate to disruption of physicians’ privacy, lack and waste of time and poor or misuse of communication [10, 16, 27, 28]. Two factors may explain such negative perceptions. First, most physicians did not report establishing rules of use. As in many countries, email communication still occurs in an unstructured way [29] and do not follow common rules such as setting limits by using system templates, limiting free text to 2–3 sentences, defining time limits and time slots to answer or systems to cover physicians’ absences [26]. Second, although patients may not be opposed to physicians billing the time spent for an email [8], most Swiss physicians do not bill email communication. Lack or inadequate compensation is a commonly reported disadvantage and is seen as a barrier to physician’s adoption of email communication [10, 17, 30].

Despite the fact that several recommendations about confidentiality have been formulated over the last 10 years [19, 31, 32], the percentage of primary care physicians in our study who did not discussing confidentiality issues in relation to email communication with their patients is similar to that reported in studies conducted in other countries 5 to 10 years earlier (36 to 60 %) [15, 16, 33]. Until quite recently, use of secured email communication was essentially reported in large health maintenance organisations [34, 35]. In Switzerland, HIN was set up to ensure the safety of email communication between health practitioners but not between physicians and patients [36]. The ongoing development of ehealth environments including administrative and messaging capabilities in addition to medical record access will definitely improve the safety of electronic communication beside [26]. However, adoption of such environments in solo or small primary care practices may take time. In the meantime, we believe that it is the role of the national health organisation systems in charge of medical regulations to acknowledge and value this type of clinical communication and set ethical and compensation guidelines in line with expected standards of care [9].

The study has several limitations. The response rate (64 %) was not optimal and a number of participants (13 %) did not complete the questions on cell phone and text message use, preventing the generalisability of our findings to all Geneva primary-care doctors. In comparison to previous surveys of doctors, our response rate, however, was high [37]. We focused on the doctors working in an urban area and it is possible that profiles of use of these different modes of communication differ in less dense areas of Switzerland or elsewhere. We did not collect data on documentation and billing of cell phone and text message communication since we did not want the questionnaire to be too long in order to favour a high response rate. Yet clinical experience suggests that these might be even lower than for email use. The questionnaire did not enable us to clearly differentiate practice patterns and perceptions between physicians handling a single, a shared or two different e-mail addresses. Finally, we did not explore the use of social media (e.g. Facebook) as a communication tool between physicians and patients. As the mean age of practicing physicians in Geneva is over 50 years, use of social media in this population is still likely to be uncommon. Health system websites, currently offered in some countries, are still in development and have not yet been implemented on a large scale in Switzerland.

This study shows that email, text message and cell phone are widely used between an urban population of primary-care doctors and their patients in Switzerland. Since electronic communication in healthcare is meant to expand with the implementation of eHealth environments in Switzerland and the collection and use of patient-generated health information [38], federal health organisations are urgently invited to establish recommendations of good use and rules for confidentiality and reimbursement. This would optimize the use of this computer-based technology and help integrate one of the ten “building blocks for a performing primary care” into the Swiss health system [39].