As the meaningful use incentive program moves into its second stage, there have been concerns among physicians over their ability to meet the patient engagement requirements. Satisfying the Stage 2 criteria will rely not only on physicians adopting the right technology, but also on their patients' willingness to use it.

Physicians say it has been a challenge changing patient behavior, and therefore the incentive money shouldn't depend on things out of their control. A recent study finds specialists may have a particularly hard time getting patients to sign up for their patient portals and exchange secure emails with them.

A study published online Feb. 21 by the American Journal of Medical Quality measured portal enrollment and use at a multispecialty fee-for-service clinic between 2010 and 2012. It found portal enrollment increased overall from 13.2 percent to 23.1 percent, but varied significantly between specialities. And primary care physicians were far more likely to exchange emails with patients than specialists.

"The study team could not investigate patients' reasons for sending fewer emails to specialists than to [primary care physicians]," the authors wrote. "But surgeons and some medical specialists who do not perform much chronic care are unlikely to generate substantial numbers of emails over time."

Stage 2 of the meaningful use program requires physicians to exchange secure emails with at least 5 percent of their patients. During the study's observation period, 87 percent of primary care physicians would have met that threshold, compared with 37 percent of other specialists.

The authors suggested specialists be given alternative requirements for meaningful use, such as providing patient education or postoperative instructions online.

Dr. Daniel Siegel, a dermatologist from Smithtown, N.Y., was not surprised by the findings and agrees with the authors' recommendations. Siegel attested to meaningful use the first two years of the program.

"I'm not sure, when we have to start dealing with the patient access to records and email, if we will continue to do it," he said.

Siegel said there are few services dermatologists can provide online for which they are compensated. If they were to encourage patients to get online and email, they would only hurt themselves by adding uncompensated care to their workloads while reducing the number of office visits, for which they are paid.

Dr. Thomas Barber, an orthopedic surgeon in Oakland, Calif., agrees specialists have a lot to worry about when it comes to the meaningful use program. But patient portals and emails don't top that list, he said.

Since 2007 he has been giving patients the option of using email as an alternative to postoperative visits. He is not compensated for these email consults, and office visits did indeed decrease. But for Barber that was a positive change. By decreasing the number of office visits, he was able to increase the amount of time spent in the operating room from one-third of his work week to half.

"I changed my practice in what most surgeons would call a desirable way," Barber said.

Barber said the key to meeting the meaningful use thresholds for email is to sign up at least 25 percent of the patient population. The study authors agreed.

They found that of the primary care physicians who had less than 25 percent of their patients enrolled to use the portal, only 12.5 percent met the meaningful use e-mail criteria. Of those who had more than 25 percent enrollment, 94.3 percent met the email criteria.

The study authors did not look at the same relationship between enrollment and email use among specialists given the low enrollment rate and low rate of emails in that group.

Physicians can be influential when it comes to encouraging portal use, Barber said. But they must be motivated to spend time promoting it to patients. He admits that when his healthcare system first adopted a portal, physicians were offered a $5,000 bonus for signing up 30 percent of their patient panels. But signing them up doesn't mean they will use the portal, Barber said.

Many specialists are not motivated to encourage emailing with patients because of the "mixed messages" sent by the government and payers, Siegel said.

"They want physicians to spend time on email," Siegel said. "If you're a physician getting an email from a patient, you read the email, you have to think about the problem, you look at the chart. You're spending time and effort, but it's uncompensated time."

For many specialists, the money lost by providing this uncompensated care will be far more than the penalties for not complying for meaningful use, according to Siegel. But that doesn't mean they are against technology adoption, he said.

When compared to primary care physicians, the number of specialists who have attested to meaningful use is significantly lower. But both Barber and Siegel agree that there are far more specialists using electronic health records than attesting to meaningful use. They are just using the technology in a way that makes economic sense to them, Siegel said.