Provider resistance to PHRs may stem from concerns about new processes and increased responsibilities associated with interacting with patients and using new health information technologies. Delbanco and Sands suggest that, "for doctors, at a time of disquiet, fatigue and bombardment by paper and electronic 'noise,' even if e-mail improves the quality of communications with patients it threatens to break the camel's back ." Given their many other responsibilities, practitioners may be unprepared to assume the role of "information broker"–helping patients look at health-related data from different sources and make informed decisions. Typically, patients are judicious in their communications and many, if not most clinician concerns are mitigated if they take the first step and start using such systems. Indeed, there is a reported decrease in 'phone-tag' and the capacity to carry out 'elective batched serial communications' by clinicians at the time of their choosing. For example, some clinicians report satisfaction from being able to leave the office, have dinner with their families, and then catch up on a few remaining patient e-mails from their home later in the evening since they can access the records via secure web portals.
▪ Physician Compensation/Incentives. Electronic patient-centered communication creates several categories of unfunded work for practitioners. The lack of compensation or other incentives for responding to patient e-mail, working with data from new sources, and facilitating informed/shared decision-making are key components of the problem. However, using standard evaluation and management (E&M) coding criteria, many electronic message threads can fulfill standard office visit reimbursement criteria (e.g., 99213).