Ensmenger found that comprehensively answering the question of why most doctors don't use email produced a sort of case study in thinking about information technologies in a sophisticated way—moving beyond what he describes as the simplistic economic and technological determinism that often dominates discussions about Internet commerce. "We can't talk about email, or the Internet, or computers as if they're one thing," Ensmenger argues. "We have to talk about them in particular business, economic and legal contexts.
According to Ensmenger's research, never in the past decade has the rate of email interaction between physicians and patients increased above six percent, despite the fact that national surveys indicate that as many as 90 percent of respondents would welcome the opportunity to communicate with their doctors via email, with 37 percent stating that they would be willing to pay for such access. The short explanation as to why this demand remains largely unsatisfied comes down to money, but there are pertinent noneconomic factors as well.
"Physicians are rarely reimbursed for Internet-based activities," writes Ensmenger. "This is certainly a powerful disincentive. And yet reimbursement is rarely cited by physicians as their principal reason for avoiding the Internet. Rather, concerns about privacy, liability, and patient safety and well-being are described as being primary."
Even allowing for a degree of calculated disingenuousness, Ensmenger reasons, physicians' collective wariness of Internet-based medicine seems to also stem from significant legal, professional and ethical concerns. "For most people, email is a very casual thing," he says. "But for physicians email cannot be casual. They have to worry about HIPAA regulations, so there has to be an infrastructure for keeping information secure. There are concerns about patient care—doctors asking, Can I adequately diagnose someone without seeing them? Email is also not something that can be easily delegated to a nurse in the same way as certain kinds of tests or paperwork."