There’s much conversation in the medical world today about how to use technology to improve health care and reduce unnecessary costs. Companies are currently racing to develop electronic medical records systems that promise to use the latest in database, encryption, and artificial intelligence programming to make medicine more efficient. But what about a form of computer technology that is much less cutting edge, so much so that even computer-shy grandmothers have embraced it?
The idea of incorporating e-mail communication into the doctor-patient relationship is far from novel, but has yet to gain a solid foothold in the health care community. Though many of us have been e-mailing at work and home for nearly two decades, a recent survey found that less than 7 percent of physicians routinely e-mail with their patients. Data shows that most patients would like to have e-mail access to their physician, and the benefits of quickly dealing with minor tasks such as prescription refills and test follow-up through the cheap form of e-mail are clear. But the survey’s results reflect the skepticism of many physicians about e-mail due to concerns about privacy, liability, compensation, and effectiveness.
Both the risks and benefits of medical e-mail communication were discussed last week at the University of Chicago Department of Medicine Grand Rounds, in a talk by visiting speaker Bernard Lo. A general internist at UCSF and director of their medical ethics program, Lo said he had fully embraced the potential of e-mail communication with patients in his practice. But that doesn’t mean he hasn’t encounter its limitations, from patients who over-use the channel to the lack of non-verbal cues from less-forthcoming patients.
For any doctor who has wasted time playing phone tag with a patient (read: all of them), e-mail should be a godsend for straightforward and simple questions, Lo said. Prescription refills, questions about medication dosage or minor side effects, and questions about referrals or appointment changes can be easily dealt with by the physician or an assistant when time allows, rather than trading voicemail messages. Lo said the more casual format of e-mail can sometimes draw out information from the patient that they may have hidden due to the stress of a visit to the doctor’s office. For some patients, talking about sensitive issues such as depression or sexual issues may be easier on a computer screen than face to face, he said.
Of course, not every medical issue can be easily dealt with over e-mail. Lo said he makes sure his patients know to call the clinic if they need an immediate answer, or 911 if they have an emergency. But many issues fall into a gray area where it’s not clear that e-mail is the appropriate way to respond. One example Lo presented to the audience was a patient who wrote about a brief flash of chest pain and her brother’s history of heart problems. Clearly, she needed to be booked for a cardiac evaluation as soon as possible, but Lo said that a crucial part of the medical response was also addressing the patient’s anxiety about her health – something the impersonal medium of e-mail might not be equipped for.
“I know she’s worried, and how do I deal with that in an e-mail?,” Lo asked.
Furthermore, the transmission of that kind of delicate information raises obvious questions about privacy and confidentiality. At UCSF, Lo said doctors and patients are instructed to use an encrypted “secure portal” that requires a special password log-in. Some hospitals are incorporating patient e-mails into their electronic medical records, which are similarly built to maintain patient privacy.
But all of those measures cost money, and the most important question about patient-doctor e-mails (especially if they are eventually billable), is whether they are cost-effective. So far, the research has been discouraging. Lo highlighted a study from the University of Michigan which found that less than half of e-mails sent by a patient required a response from a doctor – prescription refills and such could be taken care of by a triage nurse. But even with that delegation of tasks – and despite considerable patient satisfaction with the e-mail option – the number of phone calls to the clinic and doctors did not decrease.
“It appears that e-mail is something that added on to other communication with doctors and patients,” Lo said. “It’s not a replacement for those pesky phone calls.”
But since electronic forms of communication are not going away, it behooves hospitals, clinics, and smaller practices to figure out the best way to utilize e-mail and other media used by younger generations: live chats with your doctor? twitter conversations? Lo said that some patients have started sending him photos and video of injuries or other maladies, and some dermatologists have already incorporated this form of remote medicine into their practice.
“I think it’s really important to harmonize the expectations we have as doctors with the expectations patients have about this new communication technology,” Lo said. “As with everything else we do, we need to try to maximize the benefits and minimize the risks.”