Skip to main content


Log in

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

  • Original Article
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript



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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others


  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. 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.

    Article  PubMed  Google Scholar 

  3. Borowitz SM, Wyatt JC. The origin, content, and workload of e-mail consultations. JAMA. 1998;280(15):1321–4.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  5. Halamka JD, Mandl KD, Tang PC. Early experiences with personal health records. J Am Med Inform Assoc. 2008;15(1):1–7.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

  11. Viswanath K, Kreuter MW. Health disparities, communication inequalities, and eHealth. Am J Prev Med. 2007;32(5 Suppl):S131–3.

    Article  PubMed  CAS  Google Scholar 

  12. Rogers EM. Diffusion of innovations. 5th Ed. New York: Free Press; 2003.

    Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    PubMed  Google Scholar 

  17. Fishman P, Von Korff M, Lozano P, Hecht J. Chronic care costs in managed care. Health Aff (Millwood). 1997;16(3):239–47.

    Article  CAS  Google Scholar 

  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.

    PubMed  Google Scholar 

  19. Carrell D, Ralston J. Messages, Strands and Threads: Measuring Electronic patient–provider Messaging. American Medical Informatics Association Annual Session. Washington DC; 2005.

  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.

    Article  PubMed  CAS  Google Scholar 

  21. Starfield B. Threads and yarns: weaving the tapestry of comorbidity. Ann Fam Med. 2006;4(2):101–3.

    Article  PubMed  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  24. Hosmer DW, Lemeshow S. Applied logistic regression. New York: Wiley; 1989.

    Google Scholar 

  25. Liang K, Zeger S. Longitudinal data analysis using generalized linear models. Biometrika. 1986; 73:13–22.

  26. Godambe V. Estimating Functions. New York: Oxford University Press; 1991.

    Google Scholar 

  27. Fox S. E-patients With a Disability or Chronic Disease. Pew Internet and American Life Project; 2007.

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  30. Pew Internet and American Life Project. Tracking Survey: April 8th-May 11th, 2008.

  31. Bell P, Reddy P, Rainie L. Rural Areas and the Internet. Pew Internet and American Life Project; 2004.

  32. Harris Interactive. Patient/Physician Online Communication. 2008;2(8).

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

  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 

Download references


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.

Author information

Authors and Affiliations


Corresponding author

Correspondence to James D. Ralston MD MPH.

Additional information

Funding Sources

This study was funded by the Agency for Health Care Research and Quality (Grant No. R03 HS014625–01).

Human Subjects Protections Review and Approval

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

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ralston, J.D., Rutter, C.M., Carrell, D. et al. Patient Use of Secure Electronic Messaging Within a Shared Medical Record: A Cross-sectional Study. J GEN INTERN MED 24, 349–355 (2009).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: