E-Me in the Morning: Physicians and E-Mail

Barbara A. Gabriel, bgabriel@aamc.org

You’ve got mail” is hardly a new phrase in American culture. But it is not a phrase you will hear very often in a doctor’s office. Although physicians, like many Americans, have embraced e-mail as a form of communicating with family, friends, and colleagues, numerous studies indicate that they are unwilling to introduce it into their practices. Conversely, polls show that a vast majority of patients would welcome the opportunity to communicate electronically with their physicians.

In a study published in the May issue of the journal Pediatrics, researchers at Eastern Virginia Medical School revealed that after interviewing 325 patients and 37 physicians in pediatric practices, 74 percent of parents expressed interest in communicating with their children’s pediatricians via e-mail for purposes including scheduling appointments, getting lab results, and discussing symptoms.

Conversely, 79 percent of physicians said they were unwilling to communicate with patients via e-mail, citing concerns about confidentiality and that such communications would “increase” or “greatly increase” their workloads. Previous studies have found a similar divide between patients’ and doctors’ attitudes concerning e-mail as a communication vehicle for clinical concerns.

Eric J. Werner, M.D., a physician advisor for informatics and a hema-tologist/oncologist at the Children’s Hospital of the King’s Daughters and a professor of pediatrics at Eastern Virginia Medical School, is one of the authors of the Pediatrics article. Dr. Werner says that with a few safeguards, physicians stand much to gain by using e-mail as a communication vehicle with their patients.

E-mail “provides much better documentation of communications with patients as well as the opportunity to provide patients with additional information, such as an electronic file on a particular medical problem or a link to a Web site you believe could provide your patient with more in-depth information about a particular issue,” explains Dr. Werner.

He adds that improved documentation can also provide protection in malpractice suits. “Most of the medical-legal experts who talk to doctors say that improved documentation is usually an advantage in issues of medical-legal disputes,” says Dr. Werner. “In that case it should be an advantage as opposed to a telephone conversation in which any documentation at all is very limited.”

But Dr. Werner warns against introducing e-mail into a practice with- out first clarifying its limitations with patients. “Before a physician initiates e-mail contact with a patient, he or she should sit down with them and explain, ‘These are the things we would communicate electronically, and these are the things that we would not; if you think you have a medical emergency, that should not be communicated via e-mail.’”

Dr. Werner suggests that physicians who do introduce e-mail into their practices set up an automatic response to all incoming communications indicating that the message has been received and will be responded to in 24 to 48 hours and provide a phone number if the patient feels the situation requires immediate attention.

Dr. Werner currently refrains from dispensing clinical advice via e-mail due to his concerns over the security of such interactions. He is waiting for encryption technology to reach the point where he can be certain that his communications with patients will be received only by their intended recipients. “Once our practice has a secure Web site, quite frankly, I would be very comfortable using it,” he says.

Keeping in touch

William G. Adams, M.D., assistant professor of pediatrics at Boston University School of Medicine and an applied informatics fellow at the National Library of Medicine, says that he has initiated e-mail contact with a handful of his patients with more complex problems that require close monitoring.

“For patients who require continuous contact, I think e-mail is going to be essential,” says Dr. Adams. “In one case, it allows me to keep in touch with several specialists and one social worker all around a single patient.” He adds that e-mail has the unique ability to eliminate time-consuming and inefficient “telephone tag” with patients and it gives more physicians control over their schedules, allowing them to respond to patients’ queries when it is most convenient for them to do so.

Dr. Adams asserts that the best use of e-mail in a clinical setting is to treat it in the same manner as incoming telephone calls. “I think the best model would be to add a component of e-mail to the nurse triage system in which a nurse would originally receive incoming messages and then respond to them or forward them to the clinician.” That way, administrative requests involving appointment scheduling and lab results would not have to be sorted through by a busy physician.

“Just as most clinicians wouldn’t want all their patients to have their direct phone number or pager number, they wouldn’t necessarily want them to have direct e-mail access to them,” says Dr. Adams. “When I’ve spoken to clinicians in general, there have been some open to the idea of patients e-mailing them directly, while others have been resistant, fearing they would be bombarded with messages. That’s a possibility, and the reason why a triage system would be important.”

Authors of the Pediatrics article also found a correlation between e-mail access and patients’ income and education levels, leading them to fear a widening of health disparities if e-mail were to become a common form of communication between doctor and patient. Howard C. Bauchner, M.D., professor of pediatrics and public health and director of the Division of General Pediatrics at Boston University School of Medicine/Boston Medical Center, says that although studies indicate that a growing number of low-income families are gaining access to e-mail, the possibility exists that increased use of e-mail in clinical settings could lead to greater disparities.

“New technologies, if they’re good, if they work, if they’re effective, can either create greater disparities or remove disparities,” says Dr. Bauchner. “Now disparities are only real and alive if the advance works very well, and we don’t know much about how well e-mail works yet in the doctor’s office. So at the moment, I think it’s questionable about whether it will impact disparities. I’m thoroughly convinced that e-mail is going to increase patient satisfaction, but whether it improves patient outcomes outside of satisfaction is uncertain.”

Dr. Bauchner points out that besides convenience, the unique type of communication e-mail offers raises the possibility that patients will feel more comfortable using it to communicate “sensitive” matters to their physicians than they would be in face-to-face meetings. “E-mail may confer a certain sense of anonymity, allowing patients to ‘talk’ more freely about issues like abuse or sexual activity,” he says.

Dr. Bauchner has just introduced e-mail in one of his specialty clinics. “The patients love it. They’re much more satisfied. Sadly, they can get me night or day, so that’s a bit of what I worry about. On the other hand, they can get me; they don’t have to worry if I’m not home.” He adds that answering e-mail does add to his time constraints, although not to a large extent. “If spending a few minutes each day answering e-mail substitutes for longer telephone conversations, there may actually be a time savings,” he says.

Although he says that very few of his colleagues have initiated e-mail contact with their patients, Dr. Adams thinks that it is only a matter of time before it becomes the norm for practices that want to meet the needs of patient consumers. “We are not going to have a choice as physicians,” he predicts. “Patients are going to demand it, so we’re going to have to use it whether we want to or not.”

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