The Wall Street Journal
January 23, 2012
Should Physicians Use Email to Communicate With Patients?
Email has been so commonplace for so long that some people consider it nearly obsolete. But in the health-care profession, its use for communications between doctors and their patients is still controversial.
Opponents worry that doctors can't read patients by reading their emails. Important signals can be missed, they say, when doctors can't see their patients' facial expressions, hear the tone of their voices or take note of their body language, and care can suffer as a result.
They're also concerned about the security of email communications, as well as doctors' potential liability for the content and results of email exchanges.
Others say email is a valuable tool in building a relationship between doctor and patient. It makes doctors more accessible, they say, and allows a more thorough exchange of information than the traditional office visits and phone calls.
The security and liability risks, they say, can be managed, and shouldn't be allowed to stand in the way of providing an important service for patients.
Yes: It Builds Trust
By Joseph C. Kvedar
Talk about being behind the curve: Health-care professionals are among the last, if not the last, service providers to not use email to communicate with the people they serve. And it's the patients who pay the price, because email communication could help improve the quality of care they receive.
There are several reasons why many health-care providers won't use email for anything but the most basic, administrative interactions with patients, like scheduling appointments. But for many the biggest concern is possible breaches of privacy.
Sure, privacy is a problem with email. But it's a problem with any communications system. Phone conversations can be overheard, patients' paper files can be misplaced or left exposed to the view of people who shouldn't see them, and so on. Emails can also end up in the wrong hands or be read by the wrong eyes.
But such fears are overblown. Privacy can be protected to a great degree by encryption of email messages, or by the use of secure messaging applications that are often a feature of a patient portal or the electronic medical-records systems offered by physicians and hospitals.
What's more, I believe that patients understand the risks of email communication, and are willing to bear those risks in exchange for the more timely, useful and personal care that email can help bring about.
Building a Relationship
A number of studies have shown that a trusting, caring provider/patient relationship makes it more likely that a patient will follow a doctor's advice, resulting in a better outcome. And what's the most critical feature of a trusting, caring relationship? Robust, clear and frequent communication. This far into the 21st century, it's hard to conceive of achieving this goal without using multiple channels of communication.
The time doctors allot to the traditional interactions of office visits and phone conversations with patients is so strictly managed these days that it rarely allows for extended discussion. Sometimes patients can't even see a doctor without waiting for weeks, or reach a doctor directly by phone. Little wonder that so many patients feel that their doctors are inaccessible.
In my own experience, making myself available via email gives my patients a sense of direct access to me. It sends a message that I care and that I'm available to answer questions in a timely manner. It builds a bond between us that has tangible benefits for my patients' health.
Of course, not every communication between a doctor and patient is best done by email. Doctors still need to see patients in person sometimes to accurately gauge the patient's health and determine if a plan of care is being followed or whether changes in care are needed.
But there are plenty of interactions that don't require face-to-face communication and that can be more effective via email. Email messages allow for clear instructions and follow-up to an office visit, eliminating or correcting some of the misunderstandings about medications or treatment plans that can result from oral communication. Email messages also can include helpful educational information for patients and links to other resources. And they create a written record that can be useful for the doctor to refer back to.
Good for Business
There are other benefits for doctors, as well. Email communication improves efficiency. Medical practices often worry that opening a new channel of communication will overwhelm the staff with more work. A number of studies have shown this typically isn't the case. Instead, what seems to happen is that email in many cases replaces less-efficient phone tag. Most medical practices communicating with patients via email, the studies show, have seen their voice-mail volume drop.
Email can also help doctors retain patients. As new health-care models emerge, patients are gaining greater freedom to see any doctor or other health-care provider they choose, rather than being limited by prohibitive costs for venturing outside a defined group of providers. Building affinity with patients through regular communication—and providing better care as a result—can help encourage their loyalty.
Some doctors raise concerns about lack of reimbursement for email communication. But many insurers—with the notable exceptions of Medicare and Medicaid—cover online consultations. And the reimbursement landscape is changing in ways that will reward doctors for the efficiency of the care they offer patients, making email an important part of any practice.
Some doctors may also be concerned that email, as a new element of patient care, opens them up to new liability related to the content of their communications with patients, the security of those communications or other issues.
As health-care providers, our priority is to deliver the highest-quality care to our patients. Delivering that care, and communicating in any manner with patients, has inherent liability. However, we shouldn't allow potential legal issues to prevent us from delivering care in the most effective way, including email communication. With proper guidelines for such communication, and the usual diligence providers typically employ when addressing patients, any potential legal pitfalls can be overcome.
We in health care can no longer sit back and say, "I don't do email with patients." We can no longer hold back from acknowledging the improved efficiency, convenience and care that can be achieved by adding email communication to our practices. It is time to move our service delivery into the 21st century.
Dr. Kvedar is the founder and director of the Center for Connected Health in Boston, which promotes the use of information technology to improve health care. He can be reached at firstname.lastname@example.org
No: You Miss Too Much
By Sam Bierstock
It's hard to argue against something that has the power to increase communication between physicians and their patients. But given the technological and legal context of today—and with due regard for the physician's art—I have to do just that when it comes to email.
In short, email can be useful for certain very basic patient-doctor communications, such as appointment scheduling, prescription refills and questions about drug dosages. But it is no way to practice medicine.
Providing care includes an ability to interpret body language, facial expressions and other silent forms of communication that allow doctors to assess patient reactions to information about their health (apprehension, fear, anxiety) and the accuracy of their responses to questions. Online communications eliminate the ability to interpret these important signals. People also generally are more glib and careless in email interactions than they are in face-to-face meetings, again possibly masking their true condition.
By depriving doctors of the ability to interpret key patient reactions, email could diminish the quality of care delivered. Physicians also could lose control of a patient's care at a crucial moment: Patients may panic in response to an email about their condition, run to the Internet for self-diagnosis, make incorrect assumptions, or forward emails to others for advice (which may be good or bad, from qualified or unqualified individuals).
The argument that email can help build a relationship between doctor and patient that will result in better care is simply too much of a generalization. The relationship that develops in an email exchange depends on the people sending the messages. Some are sensitive, intelligent and well-meaning; others are curt, demanding and have unreasonable expectations—and are willing to run to a lawyer if anything goes wrong.
We all know that there is no shortage of attorneys willing to take on a case no matter how ludicrous the claim may be. And email is a treasure chest for malpractice attorneys. Among the questions an attorney might raise in a particular case: Did the doctor scroll down to read the entire note? How long did it take to respond to an email? What was he or she doing when the email came in, and how were the doctor's time and actions prioritized from that point on?
There are broader questions as well: What liability is associated with the accuracy or lack of accuracy of information contained in an email? What obligation does a doctor have to respond to an email from someone who isn't his patient if that person has obtained his email address from an established patient? The breadth and level of detail in electronic health records already expose physicians' thoughts and actions to analysis and criticism more than ever before. Adding email exchanges to the records increases the risk of loss of professional standing and personal assets.
Email raises privacy issues, as well. Systems exist to encrypt email, and many people who are comfortable with computers can easily deal with the extra required steps to open encrypted mail—but not everyone will be willing or able to do so. What if a patient needs help in opening encrypted mail but doesn't wish to share the information with the person they are receiving assistance from? Even if a patient can open encrypted email or can communicate with a doctor through a secure, dedicated channel online, there is no guarantee that messages will remain private—email can be forwarded, shared or misdirected entirely. Spouses, children or work colleagues may have access to a patient's email account.
Risk of Misunderstanding
There is also no guarantee that email communications between doctors and patients will be any clearer than information imparted in person—indeed, the opposite could be true. Patients' ability to understand what a doctor writes in an email varies enormously, and messages can almost always be misinterpreted, no matter how carefully they are written.
The problem again is not being able to see how a patient reacts. Without that input, it can be difficult for a doctor to judge whether a patient is fully understanding what's being communicated. So the argument that email can clarify communication between doctors and patients and thus help reduce medical errors doesn't hold water.
Even the benefit of having an email record of interactions with patients is uncertain. Besides the legal issues already raised, there are practical issues for doctors using electronic health records. These systems usually can readily capture emails, so they become part of a patient's record. But if the system doesn't capture specific information from the email—new symptoms, a recently developed allergy, a diagnosis made by another doctor—and record it in the appropriate place in the patient's record, then one of two things has to happen: Either someone has to go through each email and update the patient's record manually, or the doctor will have to review the patient's email record along with the electronic health record for each encounter with the patient.
Either way is inefficient and creates opportunities for something to be missed.
There are patient-physician email systems, including patient portals, that function well, but frequently they confine communications to nonclinical discussions such as appointment scheduling and prescription refills or instructions. When anything more important comes up, the patient is asked to make an appointment with the doctor. The doctor's office is where medicine should be practiced.
Dr. Bierstock is the founder and president of Champions in Healthcare, a health-care IT consulting group in Delray Beach, Fla. He can be reached at email@example.com
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