Microsoft Office Outlook® 2003
By Bill Crounse, M.D., Global Industry Healthcare Manager
E-mail could be a great comm unication tool for doctors and their patients. So why aren't more physicians using e-mail to keep in touch with their patients — despite the fact that 90% of consumers say they would like to communicate with their doctors online? Hey, it took a while for t he telephone to catch on, too.
At a gathering of science reporters several years ago, Dr. George Lundberg, former editor of the Journal of the American Medical Association, said that the Internet "is the most important advance in medical communications since the printing press." If Dr. Lundberg is correct, perhaps one of the Web's most useful tools for advancing medical communications is e-mail.
More than 100 million Americans currently have access to e-mail at home or at work. According to statistics gathered by the American Medical Association and Medem's Fifth Physicians' Use of the Internet study, 89% of physicians have access to the Internet and 91% of these doctors use e-mail to communicate with family and friends. Yet surprisingly, relatively few doctors currently use e-mail on a regular basis to exchange information with patients. Despite the fact that more than 90% of consumers say they would like to correspond with their doctor online, the surveys suggest only 5% to 10% of doctors use e-mail in patient care.
According to patient advocate and wellness expert Dr. Tom Ferguson, virtually 100% of consumers say they would prefer to have more "digital doctoring" available to them. "Physicians who choose not to communicate electronically with patients," says Dr. Ferguson, "are soon going to find their practices out of date."
Reimbursement: Still an issue, but change is on the horizon
Why aren't more physicians using e-mail to communicate with their patients? For one thing, because they don' t get reimbursed. As was noted in a 1998 article that appeared in the Annals of Internal Medicine, physician reaction to the emergence of e-mail seems to correlate with many of their initial concerns about the invention of the telephone. Commercially introduced in the 1870s, the telephone was greeted by physicians with mixed feelings. Many doctors expressed worry about being overwhelmed by patients seeking care over the telephone. They also voiced concern about the safety and privacy of telephone consultations. But by the mid-1920s, the telephone was fully integrated into physician practice, and today's physician couldn't be in business without one. The Annals article proclaims, "We are again on the threshold of a dramatic expansion in communications technology that may have profound effects on the patient-physician relationship and the practice of medicine."
But physicians are understandably wary of e-mail, having made what was perhaps a critical error 100 years ago when they set a standard for "giving away" their clinical acumen and services on the telephone. Unlike their brethren in law or accounting, doctors failed to set a market expectation that they should be compensated for the work they do by phone. Unfortunately, once consumers get used to getting something for free, it's hard to reverse expectations. Perhaps that's why so many physicians, when asked about e-mail, dig in their heels and say "no way" or "not until I get paid."
For doctors awaiting payment, there could be good news. Blue Shield of California has tested paying doctors for providing clinically relevant online communications with patients covered by self-insured employers. A 13-month trial showed a health expense savings of $1.87 per member, per month in the e-mail-enabled group, compared to control groups. Across the nation, other insurers are beginning to take note, and a number of plans are now reimbursing or considering reimbursing doctors for certain kinds of e-mail communications with patients.
Another growing trend is the use of electronic communications to provide second-opinion consultations. Johns Hopkins, the Cleveland Clinic, and Massachusetts General are just a few of the well-known institutions providing this type of service for a fee.
A fast and easy way to connect with patients
Even if physicians are not directly compensated for using e-mail, there are significant productivity advantages for making it a part of their communications armamentarium. One of the greatest barriers to physician-patient communications is the simple fact that doctors are very busy and oftentimes hard to reach. In that regard, e-mail offers a great promise for helping doctors and patients connect. E-mail is what's called an asynchronous mode of communication. Like voice mail, it does not depend on both parties being available at the same time. E-mail is a kind of hybrid between the written and spoken word. It offers more spontaneity and speed than letter writing, and more permanence than oral conversations. For both patients and physicians, e-mail is expedient. It helps prevent the frustrations associated with playing "telephone tag." For physicians, e-mail also avoids the typical interruptions so often associated with patient telephone calls or electronic pages.
E-mail is also a great medium to help patients get appropriate and necessary medical information. Managed care and other efforts to maximize productivity have had a significant negative impact on physician-patient communications. The average person has infrequent face-to-face encounters with his or her personal physician, and when such encounters occur, they are often brief or hurried. This is creating a widening gap in meeting people's needs for medical information. It's also happening at a time when the quantity (but not always the quality) of medical information is exploding. Today, more and more people are finding critical information about health and medicine on the Internet. However, the physician still has a central role in helping patients to understand the information they discover on the Internet and to arrive at the decisions that are most appropriate to meet their individual health needs. When information exchange is required, e-mail access and communication may be expedient and prudent for both physicians and patients.
E-mail requires etiquette
Certainly e-mail is not an appropriate means of communication in every instance. While it may be fine for making an appointment, providing routine guidance, sending visit reminders, and reporting some test results, it should not be used to communicate urgent needs or highly sensitive, abnormal, or confidential information.
Doctors should be encouraged to ask patients about their communication preferences. E-mail may be a preferred option. If so, patients should be instructed to keep e-mail messages brief and to the point. They should always include a very clear subject line in any e-mail they send. The subject line helps the doctor or doctor's staff members determine the urgency of the message and get it to the most appropriate person in the office for reply. It is also important to realize that there are limits to confidentiality when using e-mail. Even if the message is encrypted, patients should know that someone in the office other than their doctor might be able to see it. People sending or receiving e-mail at work need to understand that their e-mail is the property of their employer, and its contents may be accessible to others.
No discussion of any communication issues between physicians and patients would be complete without touching on the medical-legal implications of e-mail. Recent guidelines for the use of clinic-patient e-mail have been issued by the American Medical Informatics Association and published as a white paper in JAMA. Although the guidelines offer an extensive list of dos and don'ts for e-mail correspondence with patients, they conclude that "medical-legal anxiety should not be allowed to disable open communication as the basis for a healthy provider-patient relationship." E-mail and other communication technologies will never replace the crucial interpersonal contacts that are so essential for a successful physician-patient relationship. However, e-mail between doctors and patients offers significant promise as a way to improve access to health care, to increase the involvement of patients in their care, and to help physicians more efficiently reach out to their patients.
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About the Author
Bill Crounse, MD, is the Global Healthcare Industry Manager for Microsoft. Prior to joining Microsoft, Dr. Crounse was Vice President and Chief Medical Information Officer for Overlake Hospital Medical Center and the Overlake Venture Center in Bellevue, Washington. He is also a founder of DoctorGoodwell.Net, a company working in partnership with Microsoft to improve connectivity between physicians and their patients.