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The hidden problem when patients e-mail their doctor

Kevin | Physician | December 23, 2009

The number of physicians adopting e-mail has been distressingly low.

That’s a stark fact, especially when you consider that other industries have moved on from e-mail, using more instant forms of communication, like Twitter and other social networking tools.

There are a number of reasons, which have been discussed here in the past. They range from a lack of financial incentives for doctors to e-mail their patients to the bureaucracy that HIPAA places on electronic communication with patients.

But what if patients were allowed to freely e-mail their medical provider?

Well, sometimes you’d get long e-mails, says Bryan Vartabedian. There are some, when given the opportunity, who will write missives to their doctor, and sometimes, “too much information can cloud good communication.”

When talking face to face with patients, the conversation can be redirected. There’s no such influence in e-mail.

And consider the malpractice ramifications. As Dr. Vartabedian says, “every one of those 2,000 words is subject to legal discovery.”

Focusing electronic communication is a good idea. Patients will receive better-directed care, and office staff won’t be burdened with picking out the details within the e-mail that actually matter.

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Tagged as: Patients, Primary care, Specialist, Twitter

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  • Greg

    I can’t overstate the “too much information” factor…I made the mistake of giving out my email to patients last year. Within a few days I started getting 1000 word emails about every possible symptom the patient had, relevant or not, attached with literally megabytes of crazy “studies” culled from the internet by various alternative medicine providers, that the patients were happy to provide for my education. Needless to say I canceled that email account.

  • http://epatientdave.com e-Patient Dave

    Hi neighbor! :)

    As you might imagine, I fully understand this concern. But Kaiser’s ten years of experience with doctor-patient email has shown that it works out fine. Patients mostly don’t abuse the privilege; KP physicians report that it’s more efficient to respond to emails at end of day than deal with phone calls (which can get into protracted conversations); they’ve found that many emails eliminate the need for a visit, and others do lead to visits that wouldn’t have happened otherwise. On balance, the result is more care where it’s needed, with less annoyance.

    For my day job I recorded a podcast with KP’s Dr. Kate Christensen and Judy Derman on modernizing healthcare through IT, including this data. It’ll be published next month.

    In 1998 Dr. Danny Sands published guidelines in Jour. Amer. Medical Informatics Assn on how to do email right. This recent post includes (at bottom) a version that he printed on the back of his appointment cards. It’s swipable and reusable, if you’re interested. :-)

    I’m as concerned as anyone about not misusing physicians’ time – acutely aware of the things people like Jay Parkinson say about how the system serves neither physicians nor patients well. But I see modernizations like email and online appointment making as efficiency improvements – when used wisely and responsibly.

    *Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. JAMIA. 1998;5:104-111. Available at http://www.jamia.org/cgi/reprint/5/1/104

  • http://epatientdave.com e-Patient Dave

    Greg, I urge you to try that article and issuing those guidelines. The card image is printable “as is” or you can modify it.

    I’d be truly interested to hear what would happen in that case. I hope other docs who do email effectively will share.

    Good conversation.

  • Marcus

    As a psychotherapist, I’ve had numerous ups and downs about communicating with patients online. I’ve been blessed in that I have not received any potentially damaging e-mails from patients (attempted suicides, etc.), but I also make it clear that it’s a form of communication that is to be utilized primarily for re-arranging appointments, advising of cancellations, etc. My patients have all been respectful of that policy as it’s been clearly stated to them upfront. The one time I found it to be an issue, I followed up with an {almost} immediate phone call to the patient to discuss his concerns. Problem solved, we were able to move forward without any additional concerns.

    I, too, like the system set in place by KP that allows you to communicate with your healthcare provider via e-mail as I’m busy during the day and don’t wanna sit on hold or have a full out conversation unless absolutely necessary. To my knowledge, KP also has a secure server through which e-communication takes place. This is also an important piece given some of the previously mentioned concerns related to HIPAA and liability.

    I say go for it, but make it clear to patients what is expected of them in communicating online as well as the manner in which you will likely respond. Also, give them examples of situations where a full out or shortened telephone conversation would be appropriate and/or warranted. Our job as healthcare providers also includes education and not just treatment. Truth be told, we all stand to benefit from such modifications to the communication process. I have no doubt that this method of communicating will become ever more present as Generation Y and those behind them (read extremely tech savvy kids who are on the brink of young adulthood) begin to seek out and demand this level of communication with their healthcare providers.

    To use a timely addage, this may be a time where the old dog will have to learn a few new tricks in order to step firmly (and financially soundly) into the future.

  • http://www.pensandneedlesblog.blogspot.com Helen

    Thanks for a very helpful post.

    I have my cardiologist’s email address, and have been considering emailing him after the holidays about some bothersome symptoms. I don’t want to bug him, and I want my email to be clear and consise.

    I think if doctors and patients can make this work, it’ll be a great tool. Email is so much more convenient than phone for me, as I’m sure it is for many others.

  • Rezmed09

    E-patient Dave:
    Your two emails make the point above.

  • http://epatientdave.com e-Patient Dave

    Helen, you as a patient may find my doctor’s guidelines reassuring and practical. They’re on this card image:
    http://epatientdave.com/wp-content/uploads/2009/12/DannyCard3.jpg

    Another resource is Improving care by emailing the doctor, which cites the October 2007 Pediatrics article “E-Mailing Doctors Boosts Health Access, Quality, Study Finds” (links to iHealthBeat coverage).

    Marcus, you may be interested in this three page 1999 article [PDF] “E-psychiatry: the patient–psychiatrist relationship in the electronic age”: “This is problematic terrain.2,3 Should a psychiatrist respond to such messages at all? Should a psychiatrist answer direct questions, give advice or offer psychological interpretations by email?”

  • http://epatientdave.com e-Patient Dave

    Hi Rezmed09 – sorry, I don’t understand – which point, and how? (I presume you mean my comments, because I don’t recall having emailed with you?)

  • jsmith

    Ah, email. Yet another way to add to the pile at the end of a long day.Yet another example of how well-intentioned folks looking at their small chunk of a doctor’s time and missing its whole just might kill primary care.
    Just say no docs. We know what we do and what we cannot do. Others don’t.

  • Definitely

    Much easier to communicate with physicians this way. Then they have the luxury of sitting down to the computer when they have time instead of interrupting in-person patient time. Most likely if you’re e-mailing a doc it is less time sensitive than something you might need done face-to-face. I’m fortunate that my doctors are free with their e-mail address and mobile number.

  • http://drbobbs.wordpress.com/ DrBobbs

    I don’t understand what anybody sees in e-mail. Sure, there may be a very few instances where it’s practical, but by and large it’s risky, non-reimbursed “telephone” medicine. But because it’s “information technology” it must be better, faster, and cheaper, right?

    Wrong.

    Third party payors aren’t going to reimburse physicians every time a patient e-mails him or her that her nose is running or his back is still hurting. The system would go bankrupt inside of two months.

    Sorry, but there isn’t a tech fix for every problem.

  • http://epatientdave.com e-Patient Dave

    DrBobbs,

    Did you see the Kaiser comment above about the reality of how it’s worked out for them?

    There’s also the issue of what patients want (which I understand is not a top concern for all practices).

    A Deloitte / CHCF study released in November 2008 Many U.S. Consumers Want Major Changes in Health Care Design, Delivery reported on the results of a survey of 3,000 Americans age 18-75. One finding:

    “3 out of 4 want physicians to provide online services to get test results, schedule appointments, exchange email, access medical records (1 out of 4 say they would pay more)”

    I couldn’t find the whole report is online but I know it’s not for-sale, having been sponsored by CHCF; I’ll email it if you want.

    Again, I know physicians face many pressures (see Dr. Amy Ship’s short speech, posted on my blog yesterday). But I hope the mere fact that customers want something would count for something.

  • http://www.edocamerica.com Charlie Smith

    I’ve been e mailing patients through eDoc for about 12 years and, in addition, have a lot of patients who e mail me. I do not see patients abusing the privilege, and see it as being very beneficial to patients. The problem is that MD’s cannot realistically get reimbursed for their time and, unless you are on salary like I am, you can’t afford to do this without having the patient pay for it! And, interestingly, most insurances still do not allow reimbursement for e visits!

  • alex

    Obviously it varies depending on specialty. Limits need to be set. I would imagine it has value in primary care if you can use it to reduce the number of phone calls at the end of the day. But then you need to make sure it doesn’t expand into problems that are too complex for email, which is basically anything where you have to diagnose or rule out. I would imagine people are probably pretty reasonable about using it, but on the other hand I would imagine PCPs not being terribly enthused about another obligation at the end of the day that doesn’t pay anything. I wonder if you’re allowed to charge a fee for it since it’s not a service that falls under insurance coverage? Rather like botox or something.

  • http://www.pensandneedlesblog.blogspot.com Helen

    I’d never expect, or want, a diagnosis over email. I like email because I work in a cubicle and don’t want to announce to my colleagues that I’ve been in arrhythmia for a few days (or any other health concern, for that matter).

    It’s a simple and easy way for me to say, “Here’s what’s going on, should I come in?” without playing phone tag for three days.

  • http://www.kp.org Kate Christensen

    I’d like to chime in about our experience at KP. One of the benefits of having communications by email is that the entire interaction is part of the medical record, so that means the doctor does not need to write a note summarzing the phone conversation for the record. That means less work, plus the med-legal folks much prefer having a record of the actual exchange, rather than he-said-she-said.
    Also, we’ve seen that most messages from patients are very concise and relevant, and as Helen said above, most people are hesitant to ‘bother’ their doctors with emails. In my opinion, physicians would be wise to embrace email as we have embraced the telephone.

  • R Watkins

    e-Patient Dave:

    “But I hope the mere fact that customers want something would count for something.”

    But your reference indicates that 66% of those who want e-mail communication are unwilling to pay for it.

    My patients want no co-pays and free breakfast in the waiting room!

    Hypothetical surveys in which people check off a list of what they want are meaningless.

  • ninguem

    I wonder if the dentists get e-mails from their patients?

  • jsmith

    Definitely wrote. “they have the luxury of sitting down at the computer when they have time. “Hilarious really. I refer back to my previous post.
    Kate Christensen, Kaiser of course has a 180 degree different payment system from private practice so KPs experience is of dubious relevance. Sure, email might work in a pre-paid system where salaried docs are emailing instead of seeing pts, especially since Kaiser wants to keep pts out of the clinic and the hospital so as to make more money. In private practice docs want to get pts into the clinic, as that is the only way to get paid. In private practice, docs email in addition to seeing pts, not instead of seeing pts. Thus email might be worse than useless: more work for no more money.
    Of course, if email cuts down on the phone calls you would have to answer anyway, it might, on net, be helpful to a private doc.

  • http://epatientdave.com e-Patient Dave

    I understand your points, R Watkins, but I hope you’ll also listen to the real-world experiences of Kate and Charlie.

    To be sure, I’m pretty much incensed by the harm that’s done by insurance middlemen to physicians’ and patients’ ability to accomplish care. if practices were free to design competitive care packages (like Kaiser’s), and if patients could freely switch providers, taking their data with them, we could all see whether patients would or wouldn’t flock to someone with those online services. I’d love to see that.

  • R Watkins

    e-Patient Dave:

    Thanks for the response.

    All I can say is that my small private practice is full of Kaiser refugees, and, as I don’t use e-mail to communicate with patients, it doesn’t seem to be an issue.

  • http://epatientdave.com e-Patient Dave

    Ninguem,

    > I wonder if the dentists get e-mails from their patients?

    Mine does. He’s a member of the Pankey Institute, a whole-patient-oriented (yet business oriented) organization.

    I discovered this when I moved away from him a few years ago and asked how to find someone like him. He told me to look for Pankey-trained dentists.

    I found, interestingly, that most Pankey dentists don’t accept insurance, because they don’t want insurance getting between them and dictating what can and can’t be done. A few do. (Mine does.)

    See the ROI tab on their site, as well as history.

    I know people like Kevin are smart – no question. (Couldn’t be docs otherwise, especially not while juggling a blog like this.) I also know that too few smart people are aware of the evidence that a lot of patients want email, and the evidence that as Kate says, when well managed it really doesn’t turn out to have the anticipated problems, as understandable as those concerns are.

  • http://twitter.com/pnschmidt pnschmidt

    I built some of the systems used by Kaiser to communicate with patients, and I know how well these work. The fact that physicians are not adequately compensated to use a communication paradigm that satisfies both doctor and patient, cuts utilization, and facilitates early intervention for mild symptoms (as we found at Kaiser) is the tragedy of the American system. Clearly, such systems are best suited for routine follow-up and not diagnostic interviews and the answer to many long e-mails should be, “perhaps you need to schedule an office visit.”

    If the issue is that efficient health paradigms cannot be implemented under current health economics, there is no one (besides, I guess, Kaiser, and parts of the DoD and the VA) who is innocent. I went to a conference in 2003 where the head of a large Boston physician organization said that they did not allow as members any doc with more than a small fraction of capitated patients — capitation being a mechanism under which a good system of efficient electronic communication could provide dramatic benefits to physicians. Capitation, as implemented in the 1990′s, is not the answer, but clearly fee-for-service plans dramatically limit the options for interaction paradigms and offer no one an incentive for early, conservative intervention or efficiency. It was the efforts to eliminate capitation, rather than improve it, that yielded a system that rewards utilization. We need to change the system to align financial rewards with positive outcomes. Kaiser has done this. When will the rest of us?

  • http://drackies.blogspot.com Frank Drackman M.D.

    I e-mail my Attorney from time to time, when I don’t want the social stigma of walking into an Attorney’s Office.
    He e-mails me write back, along with a bill for his $300/hr time down to the tenth of an hour…

    Frank

  • http://epatientdave.com e-Patient Dave

    R Watkins,

    You might be surprised to hear this (or not!), but I’m tickled to hear that you have a practice of Kaiser refugees who are happy with your service! More power to you.

    I love choice, variety, diversity – I love people being able to get what they want, and I love you being able to offer it.

  • Anonymous

    >>And consider the malpractice ramifications. As Dr. Vartabedian says, “every one of those 2,000 words is subject to legal discovery.”>>

    I don’t routinely e-mail my physician, though I did when I developed an unexpected complication after a procedure, most likely as a result of her poor technique.

    What came through loud and clear via e-mail was what an ass my physician was. She made several incredibly rude and unprofessional statements. I dropped her shortly thereafter.

  • R Watkins

    e-Patient Dave:

    “I love choice, variety, diversity – I love people being able to get what they want, and I love you being able to offer it.”

    Thanks! I think what a lot of docs object to with the “new model of medicine” or whatever you want to call it, is that we’re being told (particularly within the PCMH model) that we HAVE to do this, this, and that: process is elevated to being far more important that results (i.e., better health for patients). E-mail may be great for some docs and patients, not for others. What counts is patient outcomes.

  • Rezmed09

    E Patient Dave:

    “Did you see the Kaiser comment above about the reality of how it’s worked out for them?” I have several friends working for Kaiser, and Email is a pain for them and time intensive. They were logging in from home, while making dinner and answering long winded and complex medical questions – just ripe for legal review. Kaiser did (does)not give them extra time for ALL this extra work which is why many have left the clinics and become hospitalists. It has extended their liability to more interactions. Kaiser is a great system, but we shall see how this plays out. Although it may seem like docs just don’t want to answer patients questions, I see it more an issue of how much time and energy there is in a day. Open the floodgates and people will drown – and some of them will be patients – not just docs.

    Your multiple replies and interjections of must read studies demonstrates a higher level of time commitment you are expecting from already overstretched PCP’s. This is really best suited for VIP/ Concierge medicine. It is not something that I, or most of my colleagues, could do very much of for the the next 10 years of my career. The rest of my career would either be shorter or as a hospitalist full time and giving up clinic patients that I have care for many years. That is not good medicine.

  • jsmith

    R. Watkins, “What counts is patient outcomes.” Bingo. That is the measure of our profession. Others get distracted but we should not. Email, PCMH, electronic health records, botox,new magazines in the waiting room–fluff, foolishness, child’s play all of it–unless it contributes to patient outcomes.
    When it comes down to it, quality of care, which is ours to determine, must trump service, if service gets in quality’s way. The public might not want to hear this, but true physicians are in the business of giving people what they need and not necessarily what they want.

  • http://epatientdave.com e-Patient Dave

    Hi Rezmed – I welcome your new info.

    I hope I don’t come across as a know-it-all; I’ve never worked in a medical practice. Reviewing my comments above, my sin may have been in construing reported results as reality, and you’re saying that’s incomplete. I hear you.

    Jsmith, I’m certainly interested in getting the job done, too. Not sure I agree, necessarily, with your last sentence. (Not saying I disagree, just saying “not sure I agree.”)

    Merry Christmas to all Christmas people out there. And as I say now and then to each of my clinicians, “Thank you for going into this profession and being really, really good at it.” They saved my life.

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