Patient-initiated Electronic Messages and Quality of Care for Patients With Diabetes and Hypertension in a Large Fee-for-Service Medical Group: Results From a Natural Experiment

Med Care. 2016 Mar;54(3):287-95. doi: 10.1097/MLR.0000000000000483.


Background: Few studies have examined the association between patient-initiated electronic messaging (e-messaging) and clinical outcomes in fee-for-service settings.

Objective: To estimate the association between patient-initiated e-messages and quality of care among patients with diabetes and hypertension.

Design: Longitudinal observational study from 2009 to 2013. In March 2011, the medical group eliminated a $60/year patient user fee for e-messaging and established a provider payment of $3-5 per patient-initiated e-message. Quality of care for patients initiating e-messages was compared before and after March 2011, relative to nonmessaging patients. Propensity score weighting accounted for differences between e-messaging and nonmessaging patients in generalized estimating equations.

Setting: Large multispecialty practice in California compensating providers' fee-for-service.

Subjects: Patients with diabetes (N=4232) or hypertension (N=15,463) who had activated their online portal but not e-messaged before e-messaging became free.

Measures: Quality of care included HEDIS-based process measures for hemoglobin (Hb) A1c, blood pressure, low-density lipoprotein (LDL), nephropathy, and retinopathy tests, and outcome measures for HbA1c, blood pressure, and LDL. E-messaging was measured as counts of patient-initiated e-message threads sent to providers. Patients were categorized into quartiles by e-messaging frequency.

Results: The probability of annually completing indicated tests increased by 1%-7% for e-messaging patients, depending on the outcome and e-messaging frequency. E-messaging was associated with small improvements in HbA1c and LDL for some patients with diabetes.

Conclusion: Patient-initiated e-messaging may increase the likelihood of completing recommended tests, but may not be sufficient to improve clinical outcomes for most patients with diabetes or hypertension without additional interventions.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Blood Pressure
  • Body Weight
  • California
  • Diabetes Mellitus / physiopathology
  • Diabetes Mellitus / therapy*
  • Diabetic Nephropathies / diagnosis
  • Diabetic Retinopathy / diagnosis
  • Electronic Mail / statistics & numerical data*
  • Fee-for-Service Plans / statistics & numerical data*
  • Female
  • Glycated Hemoglobin A
  • Humans
  • Hypertension / physiopathology
  • Hypertension / therapy*
  • Lipoproteins, LDL / blood
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Quality Indicators, Health Care
  • Quality of Health Care / statistics & numerical data*
  • Residence Characteristics
  • Socioeconomic Factors


  • Glycated Hemoglobin A
  • Lipoproteins, LDL