Journal of General Internal Medicine

, Volume 24, Issue 3, pp 349–355 | Cite as

Patient Use of Secure Electronic Messaging Within a Shared Medical Record: A Cross-sectional Study

  • James D. Ralston
  • Carolyn M. Rutter
  • David Carrell
  • Julia Hecht
  • David Rubanowice
  • Gregory E. Simon
Original Article



Most patients would like to be able to exchange electronic messages with personal physicians. Few patients and providers are exchanging electronic communications.


To evaluate patient characteristics associated with the use of secure electronic messaging between patients and health care providers.


Cross-sectional cohort study of enrollees over 18 years of age who were enrolled in an integrated delivery system in 2005.


Among eligible enrollees, 14% (25,075) exchanged one or more secure messages with a primary or specialty care provider between January 1, 2004 and March 31, 2005. Higher secure messaging use by enrollees was associated with female gender (OR, 1.15; 95% CI, 1.10–1.19), greater overall morbidity (OR, 5.64; 95% CI, 5.07–6.28, comparing high or very high to very low overall morbidity), and the primary care provider’s use of secure messaging with other patients (OR, 1.94; 95% CI, 1.67–2.26, comparing 20–50% vs. ≤10% encounters through secure messaging). Less secure messaging use was associated with enrollee age over 65 years (OR, 0.65; CI, 0.59–0.71) and Medicaid insurance vs. commercial insurance (OR, 0.81; 95% CI, 0.68–0.96).


In this integrated group practice, use of patient–provider secure messaging varied according to individual patient clinical and sociodemographic characteristics. Future studies should clarify variation in the use of electronic patient–provider messaging and its impact on the quality and cost of care received.


physician–patient relations electronic mail healthcare disparities 



This study was funded by the Agency for Health Care Research and Quality (Grant No. R03 HS014625–01). The authors thank Gwendolyn Schweitzer for her help in preparing this manuscript.

Funding Sources

This study was funded by the Agency for Health Care Research and Quality (Grant No. R03HS014625–01).

Human Subjects Protections Review and Approval

This study was reviewed and approved by the Group Health Center for Health Studies InstitutionalReview Board.

Conflict of Interest Statement

James D Ralston received grant funding from Sanofi-Aventis between 7/1/2004 and 6/30/2006.


  1. 1.
    Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.Google Scholar
  2. 2.
    Hobbs J, Wald J, Jagannath YS, et al. Opportunities to enhance patient and physician e-mail contact. Int J Med Inform. 2003;70(1):1–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Borowitz SM, Wyatt JC. The origin, content, and workload of e-mail consultations. JAMA. 1998;280(15):1321–4.PubMedCrossRefGoogle Scholar
  4. 4.
    Widman LE, Tong DA. Requests for medical advice from patients and families to health care providers who publish on the World Wide Web. Arch Intern Med. 1997;157(2):209–12.PubMedCrossRefGoogle Scholar
  5. 5.
    Halamka JD, Mandl KD, Tang PC. Early experiences with personal health records. J Am Med Inform Assoc. 2008;15(1):1–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Ralston JD, Carrell D, Reid R, Anderson M, Moran M, Hereford J. Patient web services integrated with a shared medical record: patient use and satisfaction. J Am Med Inform Assoc. 2007;14(6):798–806.PubMedCrossRefGoogle Scholar
  7. 7.
    Weingart SN, Rind D, Tofias Z, Sands DZ. Who uses the patient internet portal? The PatientSite experience. J Am Med Inform Assoc. 2006;13(1):91–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Zhou YY, Garrido T, Chin HL, Wiesenthal AM, Liang LL. Patient access to an electronic health record with secure messaging: impact on primary care utilization. Am J Manag Care. 2007;13(7):418–24.PubMedGoogle Scholar
  9. 9.
    Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA. 2008;299(24):2857–67.PubMedCrossRefGoogle Scholar
  10. 10.
    Ralston JD, Hirsch IB, Hoath J, Mullen M, Cheadle AD, Goldberg HI. Web-based collaborative care for type 2 Diabetes: a pilot randomized trial. Diabetes Care. 2008; In press.Google Scholar
  11. 11.
    Viswanath K, Kreuter MW. Health disparities, communication inequalities, and eHealth. Am J Prev Med. 2007;32(5 Suppl):S131–3.PubMedCrossRefGoogle Scholar
  12. 12.
    Rogers EM. Diffusion of innovations. 5th Ed. New York: Free Press; 2003.Google Scholar
  13. 13.
    Murray E, Lo B, Pollack L, et al. The impact of health information on the internet on the physician-patient relationship: patient perceptions. Arch Intern Med. 2003;163(14):1727–34.PubMedCrossRefGoogle Scholar
  14. 14.
    Brodie M, Flournoy RE, Altman DE, Blendon RJ, Benson JM, Rosenbaum MD. Health information, the Internet, and the digital divide. Health Aff (Millwood). 2000;19(6):255–65.CrossRefGoogle Scholar
  15. 15.
    Kleiner KD, Akers R, Burke BL, Werner EJ. Parent and physician attitudes regarding electronic communication in pediatric practices. Pediatrics. 2002;109(5):740–4.PubMedCrossRefGoogle Scholar
  16. 16.
    Grover F Jr, Wu HD, Blanford C, Holcomb S, Tidler D. Computer-using patients want Internet services from family physicians. J Fam Pract. 2002;51(6):570–2.PubMedGoogle Scholar
  17. 17.
    Fishman P, Von Korff M, Lozano P, Hecht J. Chronic care costs in managed care. Health Aff (Millwood). 1997;16(3):239–47.CrossRefGoogle Scholar
  18. 18.
    Moyer CA, Stern DT, Dobias KS, Cox DT, Katz SJ. Bridging the electronic divide: patient and provider perspectives on e-mail communication in primary care. Am J Manag Care. 2002;8(5):427–33.PubMedGoogle Scholar
  19. 19.
    Carrell D, Ralston J. Messages, Strands and Threads: Measuring Electronic patient–provider Messaging. American Medical Informatics Association Annual Session. Washington DC; 2005.Google Scholar
  20. 20.
    Krieger N. Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health. 1992;82(5):703–10.PubMedCrossRefGoogle Scholar
  21. 21.
    Starfield B. Threads and yarns: weaving the tapestry of comorbidity. Ann Fam Med. 2006;4(2):101–3.PubMedCrossRefGoogle Scholar
  22. 22.
    Starfield B, Weiner J, Mumford L, Steinwachs D. Ambulatory care groups: a categorization of diagnoses for research and management. Health Serv Res. 1991;26(1):53–74.PubMedGoogle Scholar
  23. 23.
    Weiner JP, Starfield BH, Steinwachs DM, Mumford LM. Development and application of a population-oriented measure of ambulatory care case-mix. Med Care. 1991;29(5):452–72.PubMedCrossRefGoogle Scholar
  24. 24.
    Hosmer DW, Lemeshow S. Applied logistic regression. New York: Wiley; 1989.Google Scholar
  25. 25.
    Liang K, Zeger S. Longitudinal data analysis using generalized linear models. Biometrika. 1986; 73:13–22.Google Scholar
  26. 26.
    Godambe V. Estimating Functions. New York: Oxford University Press; 1991.Google Scholar
  27. 27.
    Fox S. E-patients With a Disability or Chronic Disease. Pew Internet and American Life Project; 2007.Google Scholar
  28. 28.
    Baker L, Wagner TH, Singer S, Bundorf MK. Use of the Internet and e-mail for health care information: results from a national survey. JAMA. 2003;289(18):2400–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Sciamanna CN, Rogers ML, Shenassa ED, Houston TK. Patient access to U.S. physicians who conduct internet or e-mail consults. J Gen Intern Med. 2007;22(3):378–81.PubMedCrossRefGoogle Scholar
  30. 30.
    Pew Internet and American Life Project. Tracking Survey: April 8th-May 11th, 2008.Google Scholar
  31. 31.
    Bell P, Reddy P, Rainie L. Rural Areas and the Internet. Pew Internet and American Life Project; 2004.Google Scholar
  32. 32.
    Harris Interactive. Patient/Physician Online Communication. 2008;2(8).Google Scholar
  33. 33.
    Ralston JD, Revere D, Robins LS, Goldberg HI. Patients’ experience with a diabetes support programme based on an interactive electronic medical record: qualitative study. BMJ. 2004;328(7449):1159.PubMedCrossRefGoogle Scholar
  34. 34.
    Katz SJ, Moyer CA, Cox DT, Stern DT. Effect of a triage-based E-mail system on clinic resource use and patient and physician satisfaction in primary care: a randomized controlled trial. J Gen Intern Med. 2003;18(9):736–44.PubMedCrossRefGoogle Scholar
  35. 35.
    Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. Doctors who are using e-mail with their patients: a qualitative exploration. J Med Internet Res. 2003;5(2):e9.PubMedCrossRefGoogle Scholar
  36. 36.
    Carrell D. Estimating Health Plan Enrollee Race, Income and Educational Attainment from Census Data and Geocoded Addresses. Annual HMO Research Network Conference. Cambridge, MA; 2006.Google Scholar
  37. 37.
    Redesigning the practice model for general internal medicine. A proposal for coordinated care: a policy monograph of the Society of General Internal Medicine. J Gen Intern Med. 2007;22(3):400–9.Google Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • James D. Ralston
    • 1
  • Carolyn M. Rutter
    • 1
  • David Carrell
    • 1
  • Julia Hecht
    • 1
  • David Rubanowice
    • 1
  • Gregory E. Simon
    • 1
  1. 1.Group Health CooperativeCenter for Health StudiesSeattleUSA

Personalised recommendations