The pitfalls of email communication with patients

A recent article in the Wall Street Journal reviewed the emerging role of email in healthcare, arguing that doctors should more aggressively offer their patients the option to communicate with each other through email. Unlike other professionals in the United States, doctors have generally resisted the adoption of email into their practices. But according to the WSJ article, email can result in many benefits to both the doctor and patient. With email capability, patients have more immediate access to the office staff and can potentially get their problems and concerns addressed more quickly. They can also maximize their cost savings by minimizing office visits and reducing lost time from work. The author further elaborates that although doctors are not permitted to submit a charge to Medicare for email communication, they can benefit by delivering better medical care which results from the ability to monitor their patients’ conditions more closely through email.

Although these points are all valid, some areas of concern remain. In my own medical practice, I formerly used email with patients for about two years. But I eventually abandoned email and don’t ever envision going back. For sure, most patients loved using email. The option to report any symptom or concern at any time of the day without having to bother with telephone menu prompts or dealing with the hassles of making appointments proved to be tremendously convenient. And for those questions that were straightforward and consisted of hardly two sentences at most, email at times was a definite time saver.

Not infrequently, however, email could create a fair amount of inefficiency and confusion. Mostly everyone has either sent or received an email in which the content somehow did not fully convey the point intended. Despite reading, and rereading the message, the intent of the email was never fully apparent. I often felt that my responses were clear and concise, only later to learn that further clarification was required. On several occasions, I recall dispensing advice under the assumption that a patient was already taking a certain medication when in fact, they were not – all leading to confusion and the inevitable thread of emails that seemed endless. In the end, the potential back and forth that can occur with email often resulted in the need for an office visit in order to clarify the mess that was created from the original email.

Most worrisome to me, however, was the very real possibility that a diagnosis could be missed whenever an office visit was replaced by an email communication. There is an aspect of the doctor-patient interaction that that cannot be duplicated through the email process. Since the beginning of modern medicine, the face-to-face doctor-patient interaction has always been regarded as paramount to all successful medical decision making. It is only through the office visit that one can observe body language and identify other physical cues that assist in making the right diagnosis. Simply put, without this interaction you potentially miss the boat on what the patient needs.

Those on the side of more email use would counter-argue that it would only be medical issues of a “minor” degree that would be relegated to email status. That is fine, but in everyday life it is pretty much impossible for most patients to know what is a “minor” issue that is email appropriate and what is more serious and in need of a visit or immediate phone call. Seemingly trivial medical symptoms can often represent a serious condition. For patients to rely on an immediate email response or for the physician to sift through the nuances of an email to determine whether something is emergent or not becomes a gargantuan task.

I have concluded that email communication can work in a safe and efficient manner only if certain restrictions and systems are in place:

1. Security. Email should require logging into a secure system, which often requires several steps, such as entering in a medical record number and password. This would prevent any aspect of your conversation with the doctor from getting stolen. I think that it would be safe to say that many would prefer that their hemorrhoids remain a private matter and not circulating freely in cyberspace.

2. Receipt confirmation. Email sent to the Doctor should have a receipt confirmation in the form of an autoreply. In this way, the patient will know right away if their message arrived safely.

3. Word limitation. Email messages should be limited to 140 characters, similar to Twitter. Word limiations prevent patients from posing questions that are too complicated to answer by way of email. Likewise, doctor responses should be limited to the same extent. If it can’t be done in 140 characters, then the issue requires a call.

4. Word scanning. Medical email software should have a built in review process in place that scans each email created by the patient and clears it before allowing it to be sent. It would screen for “alarm” words in the email, such as “chest pain”, “stroke”, “gun-shot wound” or “suicidal”. If such words are in any way contained within the email message, then the message does not get sent and the patient gets a reply – “based on the content of your email please call the office immediately.”

5. Email delivery. It should be understood that email is read only once per day and each email sent will have only one reply. This prevents the back and forth that can happen with email use.

So patients can do all of that, and maybe get an accurate answer from the doctor. Or dare they pick up the phone and punch in 7 keys to speak with a live person, make an appointment, and have their best chance of getting the right treatment? You make the call.

Robert Sadaty is an internal medicine physician who blogs at Doc Chat.

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